Every finding on record at Heritage Living Center

Based on interviews and record review, the facility failed to protect the resident's(s') right to be free from neglect for one (Resident #1) of six residents reviewed for neglect. Specifically, the facility failed to ensure a cumulative effect of individual staff failures in the provision of care and services did not lead to an environment promoting neglect, when on 07/09/2026: - At or about 8:55 AM, CNA #1 performed a one-person pivot transfer of Resident #1 to the shower chair, in direct deviation from the resident's established care plan, which required two staff members and a mechanical lift for all transfers. Resident #1 reported to staff she heard a cracking sound and experienced pain in her leg. Cross-Reference — F689: Please refer to F689 for additional information related to this incident. - LPN #3 failed to identify and assess an acute change in condition for Resident #1 and did not notify the medical provider in a timely manner, resulting in a failure to revise the plan of care and ensure the resident received adequate pain management and timely treatment. At 9:28 AM, following pain medication administration, Resident #1 verbalized a pain level of 7/10, indicating ineffective pain relief; however, LPN #3 did not reassess, report, or follow up with the provider regarding the resident's unresolved pain. Additionally, upon CNA staff reporting Resident #1 was experiencing excruciating pain accompanied by a swollen knee, LPN #3 failed to conduct an immediate nursing assessment, further delaying the identification and treatment of the resident's condition. -CNAs #2 and #4 failed to follow the established care plan interventions for Resident #1, who was actively reporting excruciating pain at the time of care. CNAs #2 and #4 transferred Resident #1 from the shower chair to her bed utilizing a gait belt, despite staff acknowledging awareness that the resident's care plan required the use of a mechanical lift for transfers. As result of these failures, Resident #1 sustained an impacted supracondylar fracture of the distal femur, which was not identified or treated until July 10, 2026 — the day following the incident. During this period, Resident #1 reported pain levels of 10/10, indicating a significant delay in the recognition and provision of necessary medical treatment. The findings include: A review of Resident #1's quarterly Minimum Data Set, dated [DATE] revealed Resident #1 has a Brief Interview for Mental Status score of 12, indicating the resident was cognitively intact. A review of Resident #1's Medical Diagnosis report revealed Resident #1 had diagnoses which included type 2 diabetes mellitus with diabetic neuropathy, muscle wasting and atrophy, a nondisplaced fracture of greater trochanter of right femur, other disorders of bone density and structure, vitamin deficiency, presence of right artificial hip joint, anemia, other idiopathic peripheral autonomic neuropathy, repeated falls, lack of coordination, and abnormalities of gait and mobility.A review of a Care Plan indicated Resident #1 had an Activities of Daily Living (ADL) self-care performance deficit related to generalized weakness, and a history of fall resulting in right femur fracture and right humerus fracture. Care Plan interventions for transfers (initiation date of 07/17/2025) included the resident required assistance of two staff and use of a mechanical lift for all transfers. A review of Resident #1's [electronic care plan] revealed Resident #1 required two staff and the use of a mechanical lift for transfers. A review of the Progress Notes revealed a secure conversation note, dated 07/09/2026 at 11:52 PM, to the physician concerning Resident #1 complaining of pain to the right knee at a pain level of 10/10. An additional note revealed a request for an x-ray of the knee, dated 7/10/2026. On 07/10/26 at 6:28 AM, the physician answered, yes. The progress notes indicated that mobile X-ray obtained an x-ray of the right knee at 10:50AM, the Medical Doctor was notified of acute impacted supracondylar fracture of the distal femur from the radiology result received on 07/10/2026 at 10:50AM. Ortho appointment scheduled at the walk-in clinic at 1:00 PM. During an interview on 07/20/2026 at 12:45 PM, Resident #1 stated the shower aide stood the resident up without using the lift and when Resident #1 put weight on their knee they heard a cracking noise. During an interview on 07/21/2026 at 10:24 AM, CNA #2 stated they and CNA #1 transferred Resident #1 from the shower chair to the bed without using the mechanical lift. CNA #2 stated they knew the resident required a mechanical lift, stating the lift sling was seen folded and lying in Resident #1's wheelchair at the time. CNA #2 reported having thought about getting the lift and sling but decided not to. CNA #2 stated they felt they could put the resident in bed more comfortably without the lift. CNA #2 stated after they assessed the situation the lift would have been the best way to move the resident, but due to the resident begging them to get them in bed CNA#2 made the decision to transfer the resident without using the lift. During an interview on 07/09/2026 at 10:45 AM, CNA #4 stated CNA #1 asked them to help with Resident #1. CNA #4 stated they went into Resident #1's room where they noticed Resident #1 sitting in their wheelchair and complaining of pain. CNA #4 stated they went and told LPN #3 Resident #1 was in pain and that Resident #1's knee looked swollen. LPN #3 replied to CNA #4 that the resident had just been given a pain pill. During an interview on 07/21/2026 at 12:23 PM, LPN #3 stated CNA #4 informed them that Resident #1 was complaining of knee pain. LPN #3 stated they were passing medication and had pulled some narcotics, and they did not want to leave the narcotics unattended. LPN #3 stated they went to check on Resident #1 after they completed passing those medications, and when she got to the resident's room, Resident #1 was asleep. LPN #3 stated Resident #1 had received pain medication that morning at 5:37 AM and the physician had been notified about the resident's pain at the time the medication was given. LPN #3 stated they asked Resident #1 what was hurting, and Resident #1 said their leg. LPN #1 did not notify the physician that the resident continued to be in pain. LPN #3 stated they checked on the resident a couple more times during their shift and the resident was fine or sleeping. LPN #3 revealed Resident #1 had sustained a break in that leg previously and felt the pain could possibly be related to that. LPN #3 indicated there would be a progress note of their assessment of Resident #1 if an assessment was performed. A review of the Medication Administration Record (MAR) with progress notes revealed that on 07/09/2026 at 5:37AM, Resident #1 received a PRN pain medication for a pain level of 2. On 07/09/2026 at 9:28 AM, LPN #3 followed up on the effectiveness of the pain medication given at 5:37 AM, and noted the medication was ineffective with a pain level of 7. LPN #3 did not provide any further pain medication at that time and did not notify the physician. A review of the MAR Progress Note revealed, on 07/09/2026 at 3:54 PM, LPN #5 administered PRN pain medication and noted Resident #1 had a pain level of 10/10. On 07/09/2026 at 6:29 PM, a follow-up progress note written by the NP revealed a pain scale of 0 for the pain medication given at 3:54 PM. A review of the MAR Progress Note revealed, on 07/09/2026 at 11:52 PM, Resident #1 received PRN pain medication for a pain level of 10/10. LPN #5 notified physician and NP/APRN of Resident #1's complaints of knee pain with pain level of 10/10 and questioned if an x-ray should be obtained. LPN #5 noted resident received PRN pain medication at that time. During an interview on 07/21/2026 at 2:14 PM, the Administrator in Training (AIT) stated they had completed the required investigation and reporting following the initial transfer by CNA #1. The AIT stated they suspended CNA #1 pending a full investigation. The AIT revealed CNA #2 reported to them that they (CNA #1 and CNA #2) transferred Resident #1 back to the resident's bed using a gait belt because the resident was in excruciating pain. CNA #2 stated they did not use the lift because the resident did not have a lift sling under them, and they transferred Resident #1 with a two-person transfer. The AIT stated they trained CNA #2 on notifying the nurse if a resident was a mechanical lift and the resident did not have a mechanical lift sling underneath them. The AIT stated CNA #2 was also trained to let the nurse know before making the transfer. The AIT stated the resident's care plan was designed to meet the resident's specific need, and to make sure the resident was safe [staff] needed to follow the care plan. The AIT stated the staff have access to the residents' closet care plans and to the [electronic care plan], both of which indicated Resident #1 was a mechanical lift. The AIT stated a CNA cannot make an assessment to move a resident using a two-person transfer when the resident was care planned for a mechanical lift transfer. The AIT stated CNA #2 did not follow Resident #1s care plan for transfers. During an interview on 07/22/2026 at 5:03 PM, the Director of Nursing (DON) stated Resident #1 was transferred back into bed by two CNAs using a two-person transfer. The DON stated a two-person transfer was not appropriate for Resident #1 and CNAs do not have the ability to decide to transfer a mechanical lift resident using a two-man transfer. The DON stated the CNAs should have consulted with their nurse before making the two-person transfer because the mechanical lift was deemed as the safest transfer for Resident #1.If [staff] did not follow the resident's care plan an injury could occur. The DON stated the staff were trained and had access to the resident's closet care plan and the [electronic care plan], which told them the appropriate transfer to use. The DON stated the closet care plan was in the resident's closet in their rooms. The DON revealed when a nurse was informed by a CNA that a resident was in pain then the nurse should administer pain medications if the resident had an order and if not, then the nurse should call the physician. The DON reviewed the MAR with progress notes and revealed on 07/09/2026 at 5:37 AM the Resident #1 received (a prescription opioid medicine used to treat severe pain ) with a pain level of 2. The MAR showed the medication was charted as being ineffective. The DON stated LPN #3 did a follow up on the effectiveness of the 5:37 AM pain medications at 9:28 AM and documented it was ineffective with a pain level of 7. The DON indicated they did not see any action by LPN #3 regarding the pain level increase or the ineffectiveness of the pain medication that had been given at 5:37 AM. The DON revealed the resident did have other pain medications that could have been given, but they did not see documentation where any other medication had been given, or that the physician had been notified of the resident's pain level increase. During an interview on 07/23/2026 at 8:32 AM, the Nurse Practitioner (NP) stated that on 07/09/2026 at 10:00 PM, the LPN entered a message in the Electronic Health Record notifying themself and the physicians that Resident #1 was complaining of right knee pain and asked if the facility should get an x-ray. The NP stated they saw the message the following morning around 9:00 AM. The NP stated that was when they assessed the resident and noted the resident had PRN medication for pain. The NP stated the physician received the same message, and the physician ordered an x-ray and a visit to the walk-in clinic. The NP revealed Resident #1 was seen at the clinic at 1:00 PM. A review of the facility policy and procedure titled Recognizing Signs and Symptoms of Abuse/Neglect with a revised date of April 2021, revealed on item 2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Item 4 listed signs and symptoms of abuse/neglect that should be promptly reported as: injuries that are non-accidental or unexplained. A review of the facility policy and procedure for Safe Lifting and /Movement of Residents, with a revised date of July 2017, revealed on item 3. nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such an assessment shall include resident's mobility. A review of the facility policy and procedures for Care Plans, Comprehensive Person-Centered revealed, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Item 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Item 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Item 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. A review of a facility policy for Pain Assessment and Management with a revised date of October 2022, revealed on item 1. the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following a. assessing, monitoring, and modifying. 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The policy indicated the following should be reported to the physician or practitioner; Recognizing Pain, Assessing Pain, Identifying the Causes of Pain, Implementing Pain Management Strategies, Monitoring and Modifying Approaches, Documentation; Reporting. A review of CNA #1's Personnel File contained CNA #1's Functional Job Description (FJD), signed on 07/29/2015 by CNA #1.The FJD indicated Personal Nursing Care Functions: Follow patient plan of care as posted for staff in the designated location of the patient room or other area where kept. Follow patient's prescribed transfer plan, level of assistance as communicated in the designated location of the patient room or other area where kept. (I.e., mechanical lift, 2 person, etc.) Assist patient with bath functions (i.e., bed bath, tub or shower bath, etc.) as directed. Assist patients with lifting, turning, moving, positioning, and transporting patients into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. in accordance with assessed level of necessary assistance. Under the section titled, Special Nursing Care Functions the FJD indicated CNA #1 should report all patient injuries. The Personnel file also contained forms that indicated CNA #1 received training on abuse and neglect on 07/29/2015, and 03/02/2026; and the at CNA #1 signed the lifting policy on 07/29/2015. The lifting policy stated it is the policy of this facility that 2 person lifts, or the use of electronic lifts, by qualified personnel (licensed/certified staff) area mandatory at all times. Failure to follow this policy will result in immediate suspension, and, depending on the circumstances, state abuse/neglect reporting. Disciplinary action may be taken. CNA #1 signed that they watched the DVD on Mechanical Lifts and took the mechanical lift test. A review of in-service training dated 10/14/2025 revealed CNA #1 and LPN #3 received training on abuse/neglect, and resident rights. A review of CNA #2's Personnel File contained CNA #2's signed FJD with a date of 12/01/2025. The FJD indicated CNA#2's personnel functions included: Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisor. Report all allegations of patient abuse. CNA #2's Personnel File also included a signed copy of the Resident Lifting/Transfer Plan by CNA #2 dated 07/29/2025. The purpose of the policy listed was to establish procedures to ensure the safety of our employees at [the facility] who perform lifting and transfer assistance for our residents with establishing lifting/transfer requirements. Each resident's mobility upon admission will be determined, documented, and communicated to all nursing staff personnel. Resident lifting assistance will be assigned specific levels or categories in order to clearly communicate how staff is to assist the resident. The lifting/transfer assistance levels are: 1 person, 2-person, mechanical lift. Under the section of the policy titled, Communicating Lifting/Transfer Requirements, the policy indicated Closet Care Plans would be used to communicate resident lifting transfer requirements to staff. The Safety Rules was signed by CNA #2 on 07/29/2025 to indicate that CNA #2 understood that all lifting and patient transfers are done following safe lifting and transfer guidelines as lined out in the resident lifting policy. The Personnel file also contained forms to indicate CNA #2 was trained on abuse and neglect on 04/25/2026 and 05/06/2026. A review of in -service training date 02/20/2026 revealed LPN#3 received training on abuse and neglect.

Based on interviews, record review, and facility document review, the facility failed to ensure staff followed the Care Plan for one (Resident #1) of six residents reviewed. This failed practice led to an avoidable accident in which the resident obtained a fracture of the right distal femur. The findings include: Review of the Medical Diagnosis portion of the electronic health record revealed Resident #1 had diagnoses that included chronic obstructive pulmonary disease, kidney failure, type 2 diabetes, muscle wasting, and atrophy. Review of Resident #1s quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/16/26, revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS also revealed Resident #1 used a wheelchair for mobility, was dependent on staff for transferring to and from a bed to chair and was dependent on staff for getting in and out of a tub/shower. Review of Resident #1's Care Plan, dated 04/28/26, revealed the resident had a self-care performance deficit related to generalized weakness due to history of a fall resulting in right femur fracture and right humerus fracture. The Care Plan also indicated Resident #1 was dependent on two staff for all transfers with a mechanical lift. Review of an Office of Long-Term Care Reportable which contained the facility investigation reports including multiple witness statements indicated, on 07/09/26 at 8:55 AM, CNA#1 transferred Resident from their bed to a shower chair using a one-person pivot transfer. Resident #1 stated CNA#1 had the resident stand up, after standing the resident stated that they heard a crackling sound when putting their foot on the floor. CNA# 1 stated Resident #1 informed her that their leg hurt. CNA#1 stated that they did not hear a pop or crackling sound. Review of a Radiology Results Report, dated 07/10/2026 at 11:52 AM, revealed a three-view X-ray of the right knee was performed, with an impression of an acute break in the thigh bone just above the knee joint. During an interview on 07/20/2026 at 12:45 PM, Resident #1 stated the shower aide stood the resident up without using the lift and when Resident #1 put weight on their knee they heard a cracking noise. On 07/21/26 at 9:50 AM, an interview with CNA #1 revealed that the CNA entered Resident #1's room and asked the resident if they wanted a shower. CNA #1 stated that Resident #1 complained of knee pain. CNA#1 stated they told nursing staff the resident was in pain, and nursing staff stated the resident had been given pain medication earlier that morning and it was not time yet for another. The CNA then asked Resident #1 if they still wanted a shower and the resident stated, yes. CNA #1 stated they transferred Resident #1 on their own using a pivot transfer. CNA#1 stated when returning from the shower room the resident was complaining of worsening knee pain. CNA#1 stated they did not know Resident #1 was care planned for two-person mechanical lift transfers, that they should have looked at the care plan, but did not. On 07/21/26 at 1:20 PM, an interview with Assistant Director of Nursing (ADON) revealed that they were aware CNA#1 had not followed Resident #1's care plan and transferred the resident as a one-person pivot transfer. The ADON stated Resident #1 had been care planned as a two-person transfer with mechanical lift for approximately one year. The ADON stated staff were staff trained to use the resident's closet care plan when caring for residents. The ADON indicated staff have access to task information that indicates which residents are dependent or need substantial assistance. The ADON stated it was important for staff to follow resident care plans and use appropriate lift technique to prevent harm from occurring to residents. The ADON stated that the lift technique used for Resident #1 was inappropriate. On 07/21/26 at 2:14 PM, in an interview with the Administrator in Training (AIT) it was revealed the AIT was responsible for conducting trainings on reading the resident closet care plans. The AIT reported making rounds in each room weekly to ensure the care plan guides were in the resident's closets and ensuring they match the resident care plans. The AIT stated Resident #1's closet care plan was in the resident's closet, and no changes had been made. The AIT stated Resident #1's transfer requirements were for a two-person assist with a mechanical lift. The AIT stated it was important to follow the resident's care plan, due to the care plan being designed to meet each resident's specific needs and to ensure the resident was safe. The AIT stated that CNA #1 was a seasoned CNA and should have known to follow the resident's closet care plan for guidance due to Resident #1 being care planned for transfers with a mechanical lift since June of 2025. On 07/22/26 at 1:37 PM, an interview with the Administrator revealed that Resident #1 was dependent on two staff using a mechanical lift for transfers, and CNA #1 performed a one-person pivot transfer into the shower chair. The Administrator stated CNA#1 reported that Resident #1 was complaining of pain in the leg in which the resident had a previous fracture and was currently taking an as needed pain medication. The Administrator stated CNA #1 transferred Resident #1 improperly, and CNA#1 should have notified nursing staff to determine what would be the safest way to transfer the resident due to Resident #1 being in pain. The Administrator stated that transfer requirements are determined by nursing management and therapy, who complete the assessment. The Administrator stated if a resident was care planned for transfers using a mechanical lift, they should be transferred using a mechanical lift for their safety due to the risk associated with inappropriate transfers. A review of the facility policy and procedures for Care Plans, Comprehensive Person-Centered revealed, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Item 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Item 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Item 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. A review of the facility policy and procedure for Safe Lifting and /Movement of Residents, with a revised date of July 2017, revealed on item 3. nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such an assessment shall include resident's mobility. On 07/22/26 at 5:03 PM, an interview with the Director of Nursing (DON) revealed that CNA#1 transferred Resident #1 using a one-person pivot transfer. The DON stated that Resident #1 was care planned as a two-person transfer with mechanical lift and CNA#1 transferred the resident from the bed to the shower chair [using one staff and no mechanical lift]. The DON stated that staff should follow the resident's care plan because it was the safest for the resident and to prevent injuries from occurring. Review of a facility in-service dated 07/13/2026 indicated that every resident should have a closet care guide, these guides are resident specific and will lead you in providing the adequate care for each resident. If you are ever unsure about a resident's transfer status or other interventions please refer back to the closet care guide. Closet care guides are to be followed and checked daily in case anything has been updated. The facility re-educated CNA #1 on how to properly transfer a resident, the CNA was suspended for three days during the time the facility investigated the situation. The Facility also educated all direct care staff on following the closet care guide. These actions were performed before the survey team entered the facility, resulting in this finding being cited at past non-compliance.

Based on interviews and facility document review, the facility failed to utilize the Facility Assessment to ensure the minimum weekend staffing needs were met a total of 8 out of 26 weekend days, for the residents during April, May, and June of 2025, based on the Facility Assessment staffing requirements. The findings include: Review of the Facility Assessment, last updated 10/31/2024, revealed an average daily census of 125-130 residents. The Facility Assessment, last updated 10/31/2024, revealed direct-care staffing needed to ensure residents' needs were met daily, were as follows: Total Number Needed Average or Range Licensed nurses providing direct care 8-11 Nurse aides 35-50 The Facility Assessment also revealed an Individual staff assignment for nurse staffing needs by shift, for both weekdays and weekends, as follows: Day Shift CNA = Ratio 1:7 residentsDay Shift Charge Nurses = 5 totalEvening Shift CNAs = Ratio 1:10 residentsEvening Shift Charge Nurses = 5-4 totalNight Shift CNAs Ratio = 1:11 residents Night Shift Charge Nurses = 4 total A review of the Payroll-Based Journal (PBJ) report triggered excessively low weekend staffing for April, May, and June of 2025. A review of the weekend Direct Care Daily Staffing Log for April, May, and June of 2025 revealed the following staffing shortages, as required per the Facility Assessment: 04/05/2025 Day shift CNAs needed 18.9, worked 14.5 Evening CNAs needed 12.8, worked 11.5 Night CNAs needed 11.6, worked 7 Total shortage: 10.3 CNAs for census of 128 (CNA totals minimum needed per range of 35-50, worked 33) 04/06/2025 Day shift CNAs needed 18, worked 14 Evening CNAs needed 15.8, worked 12.5 Night CNAs needed 11.5, worked 8 Night Charge nurse coverage; needed 4, worked 3 Total shortage: 10.8 CNAs, 1 charge nurse for census of 126 (CNA totals minimum needed per range 35-50, worked 34.5) 04/12/2025 Day shift CNAs needed 19, worked 14 Evening CNAs needed 16.6, worked 11.5 Night CNAs needed 12.1, worked 9 Night Charge nurse coverage: needed 4, worked 3 Total shortage: 13.2 CNAs, 1 charge nurse for census 133(CNA totals minimum needed per range 35-50, worked 34.5) 04/13/2025 Day shift CNAs needed 18.7, worked 13 Evening CNAs needed 13.1, worked 13.5 Night CNAs needed 11.9, worked 9 Total shortage:8.2 CNAs, 1 charge nurse for census 131 04/19/2025 Day shift CNAs needed 18.9, worked 15.5 Evening CNAs needed 13.2, worked 13 Night CNS needed 12, worked 9 Total shortage: 6.6 CNAs for census 132 04/20/2025 Day shift CNAs needed 19, worked 13.5 Evening CNAs needed 16.6, worked 13 Night shift CNAs needed 12.1, worked 10 Total shortage: 11.2 CNAs for census 133 04/26/2025 Day shift CNAs needed 18.9, worked 16 Evening CNAs needed 13.2, worked 12.5 Night shift CNAs needed 12, worked 13 (+1) Total shortage: 3.2 CNAs for census 132 (CNA totals minimum needed per range 35, worked 41.5) 04/27/2025 Day shift CNAs needed 18.9, worked 13 Evening CNAs needed 13.2, worked 12.5 Night shift CNAs needed 12, worked 11 Total shortage: 7.6 CNAs for census 132 05/03/2025 Day shift CNAs needed 19, worked 15 Evening CNAs needed 16.6, worked 12 Night shift CNAs needed 12.1, worked 11 Night shift charge nurse needed, 4, worked 3 Total shortage: 9.7 CNAs and 1 charge nurse for census 133 05/04/2025 Day shift CNAs needed 19, worked 11 Evening CNAs needed 16.6, worked 11.5 Night shift CNAs needed 12.1, worked 10 Night shift charge nurse needed, 4, worked 3 Total shortage: 15.2 CNAs and 1 charge nurse for census 133(CNA totals minimum needed per range 35-50, worked 32.5) 05/10/2025 Day shift CNAs needed 19.2, worked15 Evening CNAs needed 13.5, worked 10.5 Night shift CNAs needed 12.2, worked 10 Evening shift charge nurse needed 4, worked 2.5 Night shift charge nurse needed, 4, worked 3 Total Shortage: CNAs 9.4, charge nurses 2.5 for census 135 (CNA totals minimum needed per range 35, worked 35.5) 05/11/2025 Day shift CNAs needed 19.2, worked 11 Evening shift CNAs needed 13.5, worked 11 Night shift CNA needed 12.2, worked 11 Night shift charge nurse needed, 4, worked 3 Total shortage: CNAs 11.9, charge nurse 1 for census 135 (CNA totals minimum needed per range 35-50, worked 33) 05/17/2025 Day shift CNAs needed 19.2, worked 15 Evening shift CNAs needed 13.5, worked 10.5 Night shift CNAs needed 12.2, worked 10 Night shift charge nurse needed, 4, worked 3 Total shortage: CNA 9.4, charge nurse 1 for census 135 (CNA totals minimum needed per range 35, worked 35.5) 05/18/2025 Day shift CNAs needed 19.1, worked 12 Evening shift CNAs needed 13.4, worked 12 Night shift CNAs needed 12.2, worked 9 Night shift charge nurse needed 4, worked 3 Total shortage: 11.7 CNAs, 1 charge nurse for census 134 (CNA totals minimum needed per range 35-50, worked 33) 05/24/2025 Day shift CNAs needed 18.6, worked 14Evening shift CNAs needed 13, worked 12Night shift CNAs needed 11.8, worked 10 Night shift charge nurse needed 4, worked 3 Total shortage: 7.4 CNAs, 1 charge nurse for census 130 05/25/2025 Day shift CNAs needed 18.4, worked 11 Evening shift CNAs needed 12.9, worked 12 Night shift CNAs needed 11.7, worked 12Night shift charge nurse needed 4, worked 3Total shortage: 7 CNAs, 1 charge nurse for census 129 (CNA totals minimum needed per range 35-50, worked 34) 05/31/2025 Day shift CNAs needed 19.1, worked 16 Evening shift CNAs needed 13.4, worked 13.5 Night shift CNAs needed 12.2, worked 13Night shift charge nurse needed 4, worked 3 Total shortage: 2.2 CNAs, 1 charge nurse for census 134 (CNA totals minimum needed per range 35, worked 42.5) 06/01/2025 Day shift CNAs needed 18.9, worked 14Evening shift CNAs needed 13.2, worked 14.5 Night shift CNAs needed, 12, worked 13 Night shift charge nurse needed 4, worked 3 Total shortage: 2.6 CNAs, 1 charge nurse for census 132(CNA totals minimum needed per range 35, worked 41.5) 06/07/2025 Day shift CNAs needed 18.6, worked 13 Evening shift CNAs needed 13, worked 16.5 Night shift CNAs needed 11.8, worked 12 Night shift charge nurse needed 4, worked 3 Total shortage: 1.9 CNAs, 1 charge nurse for census 130 (CNA totals minimum needed per range 35, worked 41.5) 06/08/2025 Day shift CNAs needed 18.6, worked 11Evening shift CNAs needed 13, worked 13 Night shift CNAs needed 11.8, worked 11 Night shift charge nurse needed 4, worked 3 Total shortage: 8 CNAs, 1 charge nurse for census 130(CNA totals minimum needed per range 35, worked 35) 06/14/2025 Day shift CNAs needed 19.1, worked 16 Evening shift CNAs needed 13.4, worked 14.5 Night shift CNAs needed 12.2, worked 8 Night shift charge nurse needed 4, worked 3 Total shortage: 6.2 CNAs, 1 charge nurse for census 134 (CNA totals minimum needed per range 35, worked 38.5) 06/15/2025 Day shift CNAs needed 19.1, worked 13Evening shift CNAs needed 13.4, worked 14.5 Night shift CNAs needed 12.2, worked 10 Night shift charge nurse needed 4, worked 2 Total shortage: 7.2 CNAs, 2 charge nurses for census 134 (CNA totals minimum needed per range 35, worked 37.5) 06/21/2025 Day shift CNAs needed 19, worked 17 Evening shift CNAs needed 16.6, worked 12 Night shift CNAs needed 12.1, worked 8 Night shift charge nurse needed 4, worked 3 Total shortage: 10.7 CNAs, 1 charge nurse for census 133(CNA totals minimum needed per range 35, worked 37) 06/22/2025 Day shift CNAs needed 19, worked 11 Evening shift CNAs needed 16.6, worked 13.5 Night shift CNAs needed 12.1, worked 10 Night shift charge nurse needed 4, worked 3 Total shortage: 13.2 CNAs, 1 charge nurse for census 133 (CNA totals minimum needed per range 35, worked 35.5) 06/28/2025 Day shift CNAs needed 18.7, worked 15 Evening shift CNAs needed 13.1, worked 12.5 Night shift CNAs needed 11.9, worked 8 Night shift charge nurse needed 4, worked 3 Total shortage: 8.2 CNAs, 1 charge nurse for census 131 (CNA totals minimum needed per range 35, worked 35.5) 06/29/2025 Day shift CNAs needed 18.6, worked 13Evening shift CNAs needed 13, worked 12 Night shift CNAs needed 11.8, worked 8 Night shift charge nurse needed 4, worked 3 Total shortage: 10.4 CNAs, 1 charge nurse for census 130 (CNA totals minimum needed per range 35-50, worked 33) In summary, according to the total number needed average or range section of the Facility Assessment, the facility was short 11.5 CNAs over the course of 26 weekend days from April - June of 2025 with a range of 35-50. According to the Individual staff assignment section of the Facility Assessment, the facility was short 223.4 CNAs and 22.5 licensed staff over the course of 26 weekend days from April - June of 2025. During an interview on 09/26/2025 at 10:17 AM, the Staffing Coordinator indicated that she does not utilize the Facility Assessment to inform staffing decisions, and instead uses a guide that was given to her when she started the job about 2 years ago. The ranges she stated to follow for weekend staffing are as follows: typically, 14-16 CNAs for day shift, 11-13 for the evening shift, and 7-9 for night shift. The Staffing Coordinator also stated she has not used the Facility Assessment to determine staffing ratios since she started the role. During an interview on 09/26/2025 at 12:10 PM, the Administrator indicated the Facility Assessment was utilized to determine staffing needs and referred to the grid that was listed and total number needed average or range, and that they meet the minimum of 35 per day. The Administrator also indicated they used the ratio grid under Individual staff assignment. The Administrator also indicated that there were usually four less CNAs on the weekend because they do not have a van driver or shower aides on those weekend days.

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review and facility policy review, the facility failed to ensure the ice machine was maintained in a clean and sanitary condition. The findings include: During an observation and concurrent interview on 09/24/2025 at 3:57 PM accompanied by the Dietary Manager (DM), the ice machine located by the kitchen door, when wiped on the inside by the DM had an accumulation of black residue where ice traveled down to the ice collector. The DM stated the ice machine had been cleaned on 09/22/2025, and that it was cleaned two times a week by a Dietary Aide (DA). She also verified that it was the only ice machine for the facility and ice was used to fill resident water pitchers and beverages at mealtimes. The DM confirmed that the ice machine was dirty with black dirt where the ice drops down to the ice collector. During an interview on 09/24/2025 at 4:03 PM, a Dietary Aide (DA#15) stated he started cleaning the ice machine two weeks ago. DA #15 stated he was educated on how to clean the ice machine by the DM and was instructed to wipe the walls on the bottom that holds the ice. He stated he saw when this surveyor had the DM wipe in the top area where the ice drops down and he had never cleaned the upper part before and was not told he had to clean it. The DA stated cleaning the ice machine was on his weekly checklist to do two times a week, but there are times it was only done once. A review of facility document titled Ice Machine Cleaning Monitoring Sheet, revealed the document included: date of the cleaning, monitoring questions with yes or no column to check and initials of the employee that performed that task. There was not a monitoring sheet for the dates of 09/15/2025-09/21/2025. There was a monitoring sheet dated 09/22/2025, that did not have staff initials for cleaning. A review of facility policy titled, Sanitation, revised October 2008, indicated ice machine and ice storage container will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. A review of facility document titled, Ice Machine Manufacturer Guidelines, revised 09/26/2022 on page 53 indicated clean and sanitize per the cleaning and sanitizing instructions provided in the instruction manual or maintenance label on the icemaker yearly. No manual provided.

Number of residents sampled: Number of residents cited: Based on observation, record review, interview, and facility policy review, the facility failed to ensure a nurse performed hand sanitation during medication administration for one (Resident #111) of one resident and failed to ensure staff followed Enhance Barrier Precautions (EBP) during care of an indwelling urinary catheter for one (Resident #16) of one resident observed for indwelling urinary catheter care. The findings include: Resident #111 A review of a facility policy titled, Administering Medications, with a revision date of April 2019 revealed medications were to be administered as prescribed and in a safe and timely way. This policy also revealed staff were to follow infection control practices, such as handwashing, antiseptic technique and gloves, as it applies to the medication administration. During an observation of the 8:00 AM medication administration on 09/25/2025, Registered Nurse (RN) #3 had prepared medications for Resident #111, which included a [brand name] 4 percent (%) patch, to be placed on the resident's skin, and [brand name] eye drops, contained in a small clear plastic tube. RN #3 put on gloves and opened the [brand name] package and removed the patch. RN #3 removed the lower peel from the back of the patch and placed it on the outer, upper area of Resident #111's right arm. RN #3 then removed the upper peel from the [brand name] patch and smoothed the patch on the resident's arm with right hand. RN #3 discarded the gloves and reached above the hand sanitizer located on the wall in the resident's room and retrieved two clean gloves and put them on without sanitizing hands. RN #3 picked up the small clear plastic tube of eye drops and used the right hand to twist the top off the tube. RN #3 held the tube of eye drops in the left hand and used the second finger on the right hand to hold the lower lid of the resident 's right eye down and instilled one drop from the tube. RN #3 then repeated the same technique to instill one drop in the resident's left eye. The nurse discarded the small tube and gloves in the trash can and then utilized the hand sanitizer on the wall, which was below the box of gloves in the resident's room to sanitize hands. During an interview on 09/25/2025 at 9:02 AM, RN #3 stated she did not know if she sanitized or washed her hands after removing the gloves used to place Resident #111's patch on or before putting on a clean pair of gloves. RN #3 stated she should sanitize her hands to not get what was on the resident's skin in the resident's eyes and to not cross-contaminate the two [medications]. During an interview with the Director of Nursing (DON) on 09/26/2025 at 6:02 PM, she stated it would be good practice for the nurse to sanitize or wash their hands between administering a topical medication and an eye drop. Resident #16 A review of facility policy titled, Enhanced Barrier Precautions, dated August 2022, revealed Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms (MRDOs) to residents. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. A review of facility policy titled, Urinary Catheter Care, dated August 2022, revealed The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. For routine perineal hygiene wear PPE such as gown and gloves. A review of a facility in-service titled, EBP, Foley Catheter Care, and Peri-Care, dated 08/08/2025, revealed EBP should be used when providing care to residents with indwelling urinary catheters such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and care of the indwelling catheter. During an observation on 09/24/2025 at 3:12 PM, foley catheter care and perineal care was provided to Resident #16 by Licensed Practical Nurse (LPN #1). LPN #1 washed her hands with soap and water then placed gloves on. A gown was not worn while providing care. LPN #1 had to lean on and over the bed to provide care since the bed would not raise up. LPN #1's clothes and legs were touching the bed when she leaned over to provide perineal care. LPN #1's right hand was used to hold the foley catheter while her left hand wiped the catheter During an interview on 09/24/2025 immediately following the observation at 3:12 PM, LPN #1 stated EBP was used only for dialysis residents. She stated she had an in-service on perineal care and foley care, but not recently and could remember it. When asked what she was supposed to do when a resident had EBP in place, she replied, I don't Know. She stated nurses and Certified Nursing Assistants (CNAs) are the ones to empty foley bags and do perineal care and it was documented on the MAR. During an interview on 09/25/2025 at 8:42 AM, CNA #2 stated, EBP was something in dietary. When asked how she would know a resident was on EBP, she stated a sign would be on a resident's door. CNA #2 stated residents with foley catheters, wounds, and isolation were on EBP. When asked if a gown had to be worn, she stated, Yes before you touch them. During an interview on 09/25/2025 at 3:16 PM, the DON stated a gown and gloves were to be worn when providing care to residents that have wounds, foley catheters, dialysis or intravenous access. In-services were provided to all clinical staff with the most recent on 08/08/2025. The DON stated she observed staff for negative outcomes or areas needed for education and planned a skills fair to be done quarterly. During an interview on 09/25/2025 at 4:03 PM, the Administrator stated EBP were for residents that have foley catheters and wounds and was used to protect the residents from germs while they get direct care. The Administrator reported the clinical staff's most recent in-service on EBP was in August.

Based on observations, interviews, record review, and facility document review, it was determined that the facility failed to protect resident rights that promote individuality and dignity for 1 (Resident #76) out of 2 residents reviewed for Resident rights. This failed practice resulted in actual harm to Resident #76 who sustained devastating psychosocial harm when the resident's hair was cut without Resident #76's permission.Based on interviews, record review, and facility policy review, it was determined that the facility failed to protect resident rights that promote individuality and dignity for 1 (Resident #76) out of 2 residents reviewed for Resident rights. A review of a Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 08/31/2025, revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #76 had diagnoses which included language disorder, loss of blood supply to the brain, anxiety, depression, and decreased brain function due to a chemical imbalance in the body. During an interview on 09/23/2025 at 11:55 AM, Resident #76 indicated, several months ago, having had a knot in the middle back of the resident's long hair. Resident #76 explained that a shower aide gave an unwanted haircut, for the purposes of getting the knot out, which totaled about 11 inches of hair being cut off. Resident #76 also indicated that once Resident #76 made a complaint, the facility bought a wig. Resident #76 pointed to a hair piece observed to be hanging on the wall in Resident #76's room. During an interview on 09/25/2025 at 8:33 AM, Certified Nursing Assistant (CNA) # 4 indicated that CNAs are not to cut a resident's hair, even if they tell them to cut their hair. During an interview on 09/25/2025 at 8:55 AM, CNA #5 indicated CNAs cannot cut a resident's hair. They are only to brush, comb, and make a resident's hair look presentable. During an interview on 09/25/2025 at 11:07 AM, CNA #6 (shower aide) indicated that CNAs are not allowed to cut a resident's hair. If a resident needs a haircut, the CNAs are to speak with the respective resident's nurse or Director of Nursing (DON). During an interview on 09/25/2025 at 11:36 AM, CNA #7 (shower aide) indicated that during a shower in April 2025, CNA #6 received permission to cut the knot out of Resident #76's hair but could not recall who gave her permission to do so. During the shower, CNA #7 stated, CNA #6 seemed to be having trouble cutting the knot out of the resident's hair, so CNA #7 helped by taking a pair of scissors and cutting Resident #76's hair. CNA #7 stated after cutting Resident #76's hair, the resident stated they did not want a haircut. During a follow-up interview on 09/25/2025 at 2:40 PM, Resident #76 reported feeling devastated after the unwanted haircut and reported still feeling devastated. Resident #76 indicated they always had long hair and pulled it back in a low ponytail because that was what looked most appropriate, and that was how most of Resident #76's family styled their hair. A review of the Grievance Log from April - September of 2025 revealed a grievance was submitted on 04/10/2025 from Resident #76 with the description of hair cut and resolved on 04/14/2025. The actions listed were CNA in-serviced; resident received complimentary wash and style from facility beautician. A review of a Progress Note, dated 06/23/2025, indicated the Assistant Director of Nursing and Social Services Representative spoke with the resident regarding the unwanted haircut and Resident #76 requested a hair piece. The Progress Note indicated Social Services was to purchase a hair piece for the resident. During an interview on 09/26/2025 at 10:04 AM, the DON indicated the facility had encouraged Resident #76 to see a beautician many times prior to the incident, but the resident refused to see the beautician. The DON also indicated that an in-service to staff was done on Resident Rights after the incident. During an interview on 09/26/2025 at 12:06 PM, Resident #76's representative indicated that Resident #76 had always had long hair, approximately down to the middle of their back. Resident #76's representative also indicated the facility did not communicate with her before or after the haircut, and that Resident #76, must still be upset about it because [Resident #76] mentions it frequently. During an interview on 09/26/2025 at 1:39 PM, the Administrator indicated they were not working for the facility at the time of the incident, but the beautician was the only one that should cut any resident's hair. A review of the facility policy titled Resident Rights, revised December 2016, reveals the right for residents to exercise his or her rights without interference and be supported by the facility in exercising his or her rights.

Based on observations, record review, interview, facility document review, and facility policy review, it was determined that the facility failed to ensure behavioral health services were provided to meet the needs of a resident with a history of suicide and a family history of suicide. Specifically, the admission nurse did not include the resident’s suicide history in the Care Plan, and facility staff were not trained to identify or respond to behavioral health needs for one (Resident #1) of one sampled resident reviewed for death. The findings include: During an observation on 08/11/2025 at 1:19 PM, all of Resident #1’s belongings had been removed from their room, except for their mattress. This surveyor observed the closet and railing where the incident took place. During an observation on 08/11/2025 at 2:25 PM, while in the Administrators office, the Administrator showed this surveyor a clear bag which contained the remaining shoestrings that were cut from the closet railing. The shoestring that was around Resident #1’s neck was left on but cut off at the neck. This surveyor then observed a pair of white and gray shoes in a box, with the strings removed. The Administrator stated Resident #1’s family wanted the residents’ remaining clothes and shoes to be donated to charity. During an observation on 08/11/2025 at 3:00 PM, the Housekeeping Supervisor showed this surveyor the large clear bag of clothes and shoes that had been removed that morning from Resident #1’s room. She stated maintenance personnel would take the bag to a donation center, as instructed by the family. During a concurrent observation and interview on 08/12/2025 at 9:15 AM, this surveyor attempted to interview Resident #1’s roommate, however, the roommate did not respond. A review of a facility document titled Facility Assessment, dated 10/31/2024, indicated the facility offered services and care related to psycho/social/spiritual support, by making sure staff that cared for the resident had the information; supported emotional well-being and helpful coping mechanisms. Staff competencies on caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or Post-Traumatic Stress Disorder (PTSD) with implemented interventions. Residents with behavioral symptoms and cognitive performance would have a nursing distribution percentage of 5.03%. A review of Resident #1’s admission Record, indicated the facility admitted the resident on 02/07/2025, for rehabilitative services due to a pubis fracture, and with diagnoses that included major depressive disorder, anxiety disorder, and a personal history of suicidal behavior. A review of Resident #1’s [Local Hospital] Geriatric Behavioral Health Documents, dated 01/09/2025-01/27/2025, indicated the resident was admitted to the Geri-Psych facility for depression, anxiety, and an intentional self-harm drug overdose. Resident #1 was administered medications for these diagnoses. Further review of Resident #1’s Geriatric Behavioral Health Documents revealed the resident had a family history of suicide, which include one immediate family member that committed suicide and another immediate family member that attempted suicide. On 01/26/2025 the day before discharge, the psychiatrist had documented the resident was withdrawn, positive for suicidal ideas, seemed lonely, and the resident mentioned to the physician they seemed a little anxious and depressed over this fall. A review of Resident #1’s admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2025, revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #1 had moderate cognitive impairment. Resident #1’s MDS also revealed the symptom of thoughts that you would be better off dead, or of hurting yourself in some way was not addressed, and the symptom of feeling down, depressed or hopeless was coded as not present. Further review of Resident #1’s MDS revealed the resident was coded as rarely for feeling isolated or lonely from those around you. Furthermore, Resident #1’s MDS revealed the resident had active diagnoses, which included anxiety disorder and depression and that the resident was actively taking an antidepressant and an anticonvulsant. A review of Resident #1’s quarterly MDS with ARD of 05/13/2025, revealed a BIMS score of 12, which indicated Resident #1 had moderate cognitive impairment. Resident #1’s MDS also revealed the symptom of thoughts that you would be better off dead, or of hurting yourself in some way was not addressed, and the symptom of feeling down, depressed or hopeless was coded as not present. Further review of Resident #1’s MDS revealed the resident was coded as rarely for feeling isolated or lonely from those around you. Furthermore, Resident #1’s MDS revealed the resident was independent in their care, had active diagnoses which included anxiety disorder and depression, and the resident was actively taking an antidepressant and an anticonvulsant. A review of Resident #1’s Care Plan, dated 02/07/2025, revealed the resident had a diagnosis of major depressive disorder, was on routine and as needed pain medication, used anti-depressant medication, and had the potential for nutritional problems related to major depressive disorder. Resident #1’s Care Plan included interventions to observe for acute sadness, interest in activities, change in sleep patterns, loss of appetite, administer medications as ordered, monitor and document side effects, and monitor for social isolation, depressive mood/behavior, anxiety, changes in usual routine, suicidal thoughts, withdrawal and insomnia. A review of Resident #1’s Care Plan Meeting Invitation, dated 07/31/2025, revealed the facility had a scheduled Care Plan meeting dated 08/13/2025 at 11:30 AM, with Resident #1 and their family. A review of Resident #1’s Physician Progress Note, dated 02/07/2025, revealed the resident had been in Geri-Psych for depression and it was found Resident #1 had not been taking their prescribed medications while at home. All of Resident #1’s behavioral medications were restarted after admission to Geri-Psych, with improvement to their mood. Resident #1 and their family opted for the resident to go to long term care. A review of Resident #1’s Medication Administration Record (MAR), dated 02/2025, revealed the resident was on a medication for major depressive disorder which was discontinued on 02/17/2025, and medications for insomnia, major depressive disorder, Parkingson’s, pain, and tremors. A review of Federal Drug Administration Package Inserts, indicated the side effects for the medications Resident #1 was taking were insomnia, depression, anxiety, suicide, disorientation, impulsive behavior, psychosis, dementia, suicidal behavior and ideation, mental impairment, abnormal thinking, and emotional instability, A review of Resident #1’s Progress Notes, dated 02/07/2025 -08/11/2025, indicated there were ongoing assessments regarding Resident #1’s behaviors. A review of Resident #1’s Social Service Note dated 02/10/2025, revealed Resident #1 had a BIMS of 12, was oriented to person, place, time, situation, and had mental function that varied over the course of the day. Resident #1’s Social Service Note revealed diagnoses which included major depressive disorder and anxiety disorder. Further review of Resident #1’s Social Service Note revealed a Patient Health Questionnaire-9 (PHQ-9) score of 00, which indicated no depression. Furthermore, the residents Social Service Note indicated Resident #1 did not have a history of difficulty coping, therefore PTSD/trauma would not be addressed on the Care Plan. A review of Resident #1’s Social Service Note dated 05/13/2025, revealed Resident #1 had a BIMS of 12, was oriented to person, place, time, and situation. Resident #1’s Social Service Note revealed diagnoses which included major depressive disorder and anxiety disorder. Further review of Resident #1’s Social Service Note revealed a PHQ-9 score of 00, which indicated no depression. Social isolation was marked as rarely, which triggered mood state to be addressed on the Care Plan. Furthermore, the residents Social Service Note indicated Resident #1 did not have a history of difficulty coping, therefore PTSD/trauma would not be addressed on the Care Plan. A review of Resident #1’s Weight Warning Progress Note dated 07/30/2025, indicated Resident #1 had dropped 5.2 pounds in one week with a food intake of 77% that day [07/30/2025]. Further review of the residents Weight Warning Progress Note revealed Resident #1 had updated their food preference on 07/28/2025 and walked around the building all day and exercised in their room. Staff were to monitor the resident weekly. A review of Resident #1’s Progress Notes revealed Resident #1 stated on a nursing general note on 02/07/2025, that Yes, I have my apartment. I am here for a little while then yeah. The residents Progress Notes also revealed nursing had multiple entries of Resident #1’s complaints of pain. A review of Resident #1’s Progress Notes revealed on 03/17/2025, Resident #1 had an increase of medication for neuropathy pain, which had side effects of suicidal thoughts and depression. A review of Resident #1’s Progress Notes revealed on 05/28/2025, Resident #1 requested the as needed pain medication to be administered at bedtime as scheduled. The resident did not like to bother staff when they were in the middle of their medication pass. A review of Resident #1’s Progress Notes revealed on 07/28/2025, Resident #1 complained of right shoulder pain and had an x-ray done with no fractures. A review of Resident #1’s Progress Notes revealed on 08/06/2025, the resident saw the physician during rounds with complaints of pain all over. The physician increased Resident #1’s neuropathy pain medication at bedtime to 200 milligrams (mg) from 100 mg, which had side effects of mood changes and increased risks of suicidal thoughts or actions. A review of Resident #1’s Progress Notes revealed on 08/10/2025, Resident #1 was found at 5:25 AM, hanging in the closet with body hanging from the neck, knees to floor, no pulse, no respiratory effort, blood pooling in feet/lower legs, skin color white, cold to the touch. Do Not Resuscitate (DNR) status was verified. A review of the Arkansas Incident Report dated 08/10/2025, indicated the police officer entered Resident #1’s room and saw the resident hanging from the coatrack of the closet by what appeared to be a shoestring. An investigation was done with the case closed as a completed offense status. A review of a facility document titled In-Service on Residents Behavior dated 08/10/2025, indicated the facility held an in-service after the incident on what to look for in a resident’s behavior, such as decreased appetite, decreased interaction, self-harm, voiced self-harm, or mental health signs or symptoms. The staff were instructed to report these behaviors immediately to the charge nurse and protect the resident. During an interview on 08/11/2025 at 1:23 PM, Licensed Practical Nurse (LPN) #1 stated she saw Resident #1 last on 08/07/2025, and was informed of the incident this morning [08/11/2025] in report. She stated the resident had walked around the facility, visited with other residents, played bingo, and never acted differently while she worked. LPN #1 stated Resident #1 was independent, while the roommate was dependent and that staff checked on Resident #1 when they provided care for the roommate. During an interview on 08/11/2025 at 1:39 PM, the Director of Nursing (DON) stated she had 34 missed calls, on 08/10/2025, the morning the facility tried calling her. She arrived at the facility around 6:00 AM, and the police had left, but the coroner was still there. The Administrator and DON spoke to the night shift Registered Nurse (RN) #5, and asked if Resident #1 acted any out of the ordinary and the nurse stated, No. The DON stated Resident #1 had gotten new tennis shoes last week and walked into the DON’s office to show them to her. The resident sat down in a chair and bragged about getting a size 15 shoe, when they wore an 11, because the resident said they did not like their shoes tight. The DON described Resident #1 to have been a very tall person, around 6 feet. During an interview on 08/11/2025 at 1:56 PM, the Activities Director (AD) stated Resident #1 was a very tall person around 6 feet, and participated in the facility activities, especially bingo. The AD stated Resident #1 was always smiling. During an interview on 08/11/2025 at 1:58 PM, the Assistant Director of Nursing (ADON) stated she arrived at the facility on 08/10/2025, between 6:40 AM-6:50 AM, after the investigators and coroner arrived. The ADON stated she saw them cut Resident #1 down and let Resident #1 fall to the floor. The resident landed on their right side with their back facing the closet with the front of the body facing the footboard of the bed, and their legs bent. Resident #1 had on a white t-shirt and boxers, no socks or shoes. Resident #1’s roommate had already been removed. The ADON stated Resident #1 had an increase to their medication last week for pelvic pain and neuropathy and the physicians saw Resident #1 every other Wednesday for pain. During an interview on 08/11/2025 at 2:12 PM, the Administrator, the Nurse Consultant, and a member of the governing body were in the Administrators office. The Administrator stated she was notified around 5:30 AM, by RN #5 that a resident had hung themselves. The Administrator stated, I instructed her to call 911 and the police. I arrived at the facility at 6:00 AM and received an update from the staff. The family had been notified by the RN on duty prior to my arrival. The coroner informed the Administrator that Resident #1 was found with shoestrings around their neck and was on their knees. The Administrator stated she did not know Resident #1 and had only met them just a couple of times, since she started in July of 2025. She stated she looked through Resident #1’s cell phone to see if there had been a note or message left. The Administrator confirmed no note or message was found, and the last text was sent to the resident’s family member around 10:30 PM, with no typed message just a picture of a green tractor. Resident #1’s dresser drawers were also checked for a note, and nothing was found, per the Administrator. During an interview on 08/11/2025 at 4:25 PM, the Deputy Coroner stated he was notified around 5:57 AM and arrived on scene at 6:09 AM. The Deputy Coroner stated, as he was walking through Resident #1’s room, he took pictures. He stated he noticed there were two beds in the room, a curtain divided the two beds, and it was pulled open so both beds were visible. The right closet door was opened about 90 degrees, so you could not see inside of the closet from the doorway. The Deputy Coroner stated when he stepped around the door, Resident #1 was hanging by the neck, it was later determined it was shoestrings that were used. Resident #1 was 6’ tall. He verified Resident #1 had tied the knot that put pressure on the front of their neck and had the strings so tight that it cut off the carotids and the resident probably passed out after 15-20 seconds. The Deputy Coroner stated the shoestring was tied at the highest point in the closet, the residents’ knees were bent 90 degrees, and their feet were toward the outside of the closet. There were deep ligatures in the front of the neck, where most of the pressure was and along the jaw line, lower mandible of the neck. There was mild blood pooling in the residents' lower legs when the coroner arrived and was worse before he left. The Deputy Coroner stated rigor mortis had not set in yet, which usually takes four to five hours and would have started in the jaw and neck area, but since the resident was hanging, it would not be seen due to the trauma of the neck area. He then stated the residents’ fingers and arms were still pliable, and that a nylon shoestring was strong enough to withstand Resident #1’s weight and hanging. The Deputy Coroner stated no foul play was suspected, and that he spoke to Resident #1’s family member on the cell phone while at the hospital and the family member stated, [the resident] finally did it and had talked about doing it for a long time. The resident hated being in the nursing home and admitted self to the facility to not be a burden on the family. The Deputy Coroner stated, if a person was thinking of suicide and they had a plan, they would act normal to force people and make people think they were okay. During an interview on 08/11/2025 at 4:52 PM, CNA #2 stated she was the one that found Resident #1 in the closet. She stated she was working the hall with two other CNAs and the female residents on the 400-hall did not want male staff to change their briefs, so the CNAs decided to split the hall. CNA #2 and CNA #6 would round on the female residents, and CNA #3 would round on the male residents. CNA #3 checked the residents in Resident #1’s room at 2:30 AM. At 5:25 AM, CNA #2 and CNA #6 finished the female residents before CNA #3 finished the men, so CNA #2 went into Resident #1’s room to change, dress, and get up the dependent roommate. CNA #2 turned on the night light so it would not wake up Resident #1. As CNA #2 was walking to the closet, she noticed Resident #1 was not in bed and assumed the resident had already gotten up and walked to the kitchen, so she opened both of the closet doors. CNA #2 stated she had to let her eyes adjust because it was still dark in there but noticed Resident #1’s feet and jumped back and was about to help, when she saw Resident #1 was hanging. She stated, I freaked out, screamed, and took off running down the hall. CNA #2 stated she could not get the words out. CNA #3 took off to Resident #1’s room and came out and stated to RN #5, Oh my God, the resident hung themself. CNA #2 stated the RN told the CNAs they had to remove the roommate immediately, but CNA #2 said, I could not go back in there. CNA #2 confirmed she wrote a statement for the police and facility without coercion from anyone at the facility on the wording used in the statements. During an interview on 08/11/2025 at 5:20 PM, CNA #3 stated when he got to work on 08/10/2025, there were three CNAs scheduled on that hall and he immediately thought to himself, we are going to have a good night. The CNA stated the CNAs split the hall, and he had all the male residents. The CNAs did rounds at 2:30 AM and again around 5:25 AM. CNA #3 stated he had gotten behind, so CNA #2 walked into Resident #1’s room to help CNA #3 finish the hall. CNA #3 stated he heard a scream and CNA #2 came running out of the room, so he asked CNA #2 what happened, and CNA #2 could not talk, but said closet. CNA #3 stated he walked into Resident #1’s room, saw the closet doors were opened and saw Resident #1 hanging. CNA #3 revealed he was freaked out. CNA #3 described Resident #1 as having had on a white t-shirt and boxers, their legs were really purple and bent, the front of their body was facing the left wall of the closet, and the resident’s knees were not touching the bottom of the closet, they were about six inches from the ground. CNA #3 described the resident as a tall person, around 6’-6’1 inch. CNA #3 stated, You see this on television and think that is all made up, but it is not. All the resident had to do was put their feet down and stand up. CNA #3 stated he could not see Resident #1’s neck area, the residents’ head was hunched over, and their eyes were halfway closed. CNA #3 stated staff immediately got the roommate out of the room and left Resident #1 alone until the police arrived. CNA #3 then stated staff locked down the hall and kept all the residents in their rooms, until things settled down. During an interview on 08/12/2025 at 9:22 AM, Resident #2, a resident on the 200-hall, wheeled themselves in a wheelchair down the 400-hall towards Resident #1’s room when this surveyor asked the resident their name. The resident stated the last time they saw Resident #1 was on Saturday, 08/10/2025, during the day. Resident #2 stated Resident #1 always complained of headaches and neuropathy, did not like the food here, and often spoke about how sad they were because their spouse passed away 10 years ago. Resident #2 stated they received a voicemail Saturday night with Resident #1 being a jokester asking if I wanted to go out to eat dinner, then said oh yeah, we cannot leave the facility. Then Resident #2 stated Resident #1 said, Thank you for the refrigerator, I will see you at church in the morning. Resident #2 stated, staff told me that [Resident #1] did not wake up. During an interview on 08/12/2025 at 12:22 PM, CNA #4 stated she worked with Resident #1 all the time and gave the resident a shower on Saturday, 08/10/2025. She stated the resident never acted differently than normal. CNA #4 revealed Resident #1 was independent and would get their roommate ice water and would go to Resident #2’s room on the 200-hall to visit. She stated, the resident did make statements all the time about missing their spouse and did not understand why God kept them here but never made statements of suicide or comments related to what happened. During an interview on 08/12/2025 at 3:36 PM, RN #5 revealed she was late administering medications on Saturday night, 08/10/2025, and informed Resident #1 of it, to which the resident responded, No rush. During rounds at 2:30 AM, Resident #1 was in bed. RN #5 stated she always saved Resident #1’s rooms morning medications for last, so the residents could sleep longer. RN #5 stated as she was at the end of the hall when she saw CNA #2 running out of Resident #1’s room and was hysterical. RN #5 stated CNA #2 was shaking and backing down the hall toward the desk. CNA #3 heard CNA #2 scream, came down the hall and entered Resident #1’s room. CNA #3 came out and told RN #5 what happened, and RN #5 ran into the room and saw Resident #1 hanging with their body toward the window. The resident had a string around their neck, their legs were bent, their knees were off the floor, and their feet were touching the floor. RN #5 stated she checked Resident #1 for a pulse and respiratory effort, but there was not any. RN #5 stated she knew the resident had a DNR code status. She described that Resident #1 was cold to touch, pale, white, and their legs were reddish in color. RN #5 stated she called the DON and ADON, with no answer. She then called the Administrator, 911, the police, and Resident #1’s family. RN #5 reported off to each of them as they arrived. The Deputy Coroner arrived and spoke to Resident #1’s family member on the cell phone. RN #5 stated she never knew Resident #1 had a recent suicide attempt before admission to the facility, but she had overheard Resident #1’s family member tell the coroner that. RN #5 stated staff did close the 400-hall doors to block traffic and kept all residents in their rooms until everything calmed down. Resident #1’s roommate was immediately removed from their room, prior to the arrival of the police. During an interview on 08/12/2025 at 5:03 PM, CNA #6 stated when she got to work on 08/10/2025, there were three CNAs for the 400-hall, so they split it up the residents by male and female. CNA #2 and CNA #6 would take care of all the female residents and CNA #3 would take care of the male residents on the 400-hall. CNA #6 stated they made rounds at 2:30 AM, and she never saw Resident #1 at that time, but CNA #3 did. At 5:25 AM, CNA #6 stated they finished the female side before the male side, so they helped CNA #3 finish the male residents in order to be done. CNA #2 entered Resident #1’s before CNA #6 made it up there and as CNA #6 was putting her gloves on she heard a scream, and CNA #2 came running out of Resident #1’s room hysterically. CNA #6 revealed she went into the room and peeked around the corner, saw Resident #1 hanging with something white around their neck. The residents' legs were bent, they had a t-shirt was on, there was a shirt on a hanger laying across Resident #1’s bed, and CNA #6 revealed she took off running. CNA #3 went into the resident’s room and came out to report to RN #5. RN #5 then went into Resident #1’s room and started calling management, the police and 911. CNA #6 stated RN #5 instructed us to get the roommate out of the room. CNA #6 revealed she could not go back in the resident’s room. CNA #3 and CNA #7 immediately removed Resident #1’s roommate. CNA #6 stated she was given a statement to write by RN #5 and was instructed to put the last time she saw the resident was at 2:30 AM, but I did not see the resident at that time, so I did not put that down on my statement. During an interview on 08/13/2025 at 8:26 AM, LPN #8 revealed to know how to care for a resident, they were to look at the residents' closet Care Plan, look in the chart, or ask staff that had worked with the resident. LPN #8 stated the admitting nurse would fill out the closet Care Plan, if it was at night. During the day, the ADON or nurse would fill it out. If a resident had a history of suicide or suicidal ideations, it would be on their Care Plan or in their chart. LPN #8 stated she did not know Resident #1 had a prior suicide attempt. During an interview on 08/13/2025 at 8:36 AM, the Admission’s Coordinator (AC)/Medical Records/Infection Preventionist stated the admission of a resident was done by a group of people. The AC stated she would be informed when a resident was coming to the facility, and the diagnoses codes were entered along with details and orders. The AC stated she would take the telephone report and pass it to the nurse that would receive the resident. The AC revealed whatever nurse was on duty that day, would do the admission. The AC stated the facility had standard orders they followed and if a discharge packet was received, she entered the medications in the queue but did not activate them. Then the doctor would review the medications, and they would get activated. If the doctor wanted to make changes, he would call the facility. The AC then stated the MDS Coordinators did the assessments. During an interview on 08/13/2025 at 9:27 AM, RN #9 stated she had been the treatment nurse for the past two weeks, and prior to that was the RN on the 400-hall. To care for a resident, staff looked at the closet Care Plans, physician orders, talked to aides for residents’ personal preferences, and talked to the residents if coherent. RN #9 stated she worked with Resident #1 up until two weeks ago. RN #9 stated Resident #1 did not act differently and saw Resident #1 on Saturday, 08/10/2025. She revealed the resident told her They tricked you into coming in on Saturday, because Resident #1 liked to joke with people. Resident #1 mentioned having depression problems. RN #9 stated if a resident had a history of a suicide attempt, she thought it would be on the residents Care Plan, but she had never had a suicidal resident before. RN #9 stated she was not aware of looking for anything suicide related for Resident #1. RN #9 stated if a resident mentioned something odd or had behaviors, she would report it and would mention it to the CNAs. Resident #1 only saw the general doctors at the facility. The resident was an insanely sweet person and joked a lot; always sat around the fireplace and talked to everyone. I never saw it coming. During an interview on 08/13/2025 at 10:04 AM, CNA #4 stated she would look in the closet at the closet Care Plan to know how to care for a resident, or the nurses would mention what to do. CNA #4 stated if a resident was suicidal or had thoughts about it, the nurse would tell staff to watch out for it. CNA #4 stated no staff were aware that Resident #1 had tried to commit suicide prior to admission and was not told to look for anything on Resident #1. CNA #4 stated the resident did not see a psychiatrist, only the two general doctors at the facility. During a concurrent interview on 08/13/2025 at 10:10 AM: The Long-Term Care (LTC) MDS Coordinator, stated if a resident was admitted to LTC, she did the paperwork. Once a resident transitioned from rehab to LTC, she monitored the residents quarterly MDS. The LTC MDS Coordinator stated she would receive the resident’s information from a recent hospital stay or skilled services, and from their primary care physician (PCP) to develop the Care Plan. She then stated CNA documentation was looked at to add to the Care Plan. The LTC MDS Coordinator revealed she did not know Resident #1 had a suicide attempt prior to admission. Resident #1 always spoke, sat by the fireplace by the outside windows, loved to play bingo, and had to exercise and walk all the time. The Medicare Manager Rehab (MMR)/MDS Coordinator, she stated if a resident was admitted to rehab, she did the paperwork. She stated different people would input in the MDS, which included social services, dietary staff, the treatment nurse, and the activities director. When specific questions were answered on the MDS, it triggered for the Care Plan. The MMR MDS stated she received information from therapy to get function levels of the residents, from the nursing admission screen, documents from the hospital or from the facility the resident came from. It was a collaboration based on history from the PCP and inputs from other designations, such as nursing, and therapy. If a resident had a history of suicide attempts or ideation, it would be in their history and physical, care plan, and medical diagnoses. The MMR/MDS Coordinator stated she recalled reading Resident #1 overdosed on medications prior to being admitted to the facility and had been admitted to a Geri-Psych facility where the resident had sustained a fall and was subsequently sent to the hospital. The resident was then discharged home and then admitted to the nursing home facility per the decision of the resident and family. The MMR MDS stated when a resident was admitted with a major depressive disorder, the primary focus was for the current diagnosis and with that being said, hopefully being medicated and interventions would apply to that diagnosis. Suicide was not current diagnosis for Resident #1. She stated Resident #1 did not see a psychiatrist while at the facility, simply because the resident only saw that one while in the facility, no follow up was ordered and nursing documentation did not reference a change in behavior for the general doctors here to refer the resident to a psychiatrist. During an interview on 08/13/2025 at 10:47 AM, the DON stated staff would not know if a resident had a history of suicidal thoughts or attempts and would only know of active diagnoses. The DON stated, I think I knew Resident #1 had attempted suicide but had forgotten about it then re-read their paperwork after the incident. The resident did not have any signs or symptoms while here to remind us of the attempt. The DON stated Resident #1 did not have a follow up scheduled with a psychiatrist, so they only saw the general doctors at this facility. If the doctors saw any issues, they would have referred to a specialist. The resident’s family member told the coroner that the resident finally did it. The DON stated, you would think if they felt that way, they would have said something to us or that the resident was capable of doing this and would have shared that with us at the facility. I do not know if it would have changed the outcome but at least we would have known it. During an interview on 08/13/2025 at 2:20 PM, Administrator in Training (AIT) stated, she had started this position in the middle of June and had been the Social Director for the past 5.5 years. She worked with Resident #1 from February to June, and stated the resident was admitted in February to [TRUNCATED]

Based on observation, record review, and interview the facility failed to ensure dietary staff washed their hands and changed their gloves before handling food items to prevent the potential for cross contamination for the residents who received meals from 1 of 1 kitchen; Hot food items were not maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 127 residents who received meals from the Kitchen. The findings are: 1. On 06/02/24 at 10:30 AM, Dietary Aide (DA) #1 turned the sink on and washed her hands. She used her bare hands to turn off the faucet, contaminating her hands. Without washing her hands, she picked up plates, and placed them in the plate warmer and placed the bowls on a shelf with her fingers inside of them. 2. On 06/02/24 at 10:35 AM, DA #1 turned on the hand washing sink and washed her hands. She turned off the faucet with her bare hands, contaminating her hands. Without washing her hands, she picked up picked up glasses by their rims and placed them on the shelf close to the steam table. 3. 06/02/24 at 10:43 AM, the drawers below the counter where serving utensils were stored was rusty. 4. On 06/02/24 at 10:54 AM, a container of rice crisper was on a shelf in the storage room and was not fully covered, exposing it to air or other contamination. 5. 06/02/24 at 11:09 AM, DA #3 was wearing gloves on her hands, when she picked up a spray bottle from the cabinet and spread inside the pan. Contaminating the gloves. Without changing gloves and washing her hands, DA #3 removed biscuits from the box and placed them on the pans to be baked and served to the residents for noon meal. 6. On 06/02/24 11:17 AM, the following beverage containers on a shelf in the refrigerator were not covered, exposing them to cross contamination. a. A pitcher of tomato juice. b. A pitcher of cranberry juice. c. A pitcher of orange juice. d. An opened box of sausage. The box was not covered or sealed. e. An opened box of chicken. f. The were 2 boxes of coffee on a shelf with received date of 05/15 on it. The manufacture specification on the box documented, Keep Frozen. 7. On 06/02/24 at 11:20 AM, DA #1 turned on the hand washing sink and washed her hands. She turned off the faucet with her bare hands, contaminating her hands. Without washing her hands, she picked up individual napkins, placed utensils inside, and wrapped them for the residents to be used during the noon meal. When the surveyor asked DA #1 what the residents use the napkins for. DA #1 stated, to wipe their mouth when eating their meal. The surveyor asked DA#1 what should you have done after touching dirty objects and before handling clean equipment? DA #1 stated, I should have washed my hands. 8. On 06/02/24 at 11:25 AM, DA #2 used a 4-ounce spoon to place 21 servings of scalloped potatoes into a pan from a pan on the steam table, contaminating her hand. DA #2 then picked up a clean blade from a clean rack and placed it inside the blender, after that, DA #2 set the blender on the counter. Holding onto the metal bar attached to the blender motor, DA #2 pulled the motor towards the edge of the counter. Without washing her hands, DA #2 picked up the blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets for noon meal. At 11:28 AM, the surveyor asked the DA #2 what should you have done after touching dirty objects and before handling clean equipment? DE #2 stated, I should have washed my hands. 9. On 06/02/24 at 11:31 AM, the following food items on a shelf in the walk-in freezer had no date when opened to ensure first in and first out. a. Two boxes of cookies. b. A box of broccoli. c. An opened of pork fritters was not covered or sealed. d. The floor in the walk-in freezer had an accumulation of sheet of ice on it. Dietary Manager #1 and #2 stated, Water comes from under the ground whenever it rains. 9. On 06/02/24 at 12:13 PM, the temperature of the food item on the steamtable was checked and read by DA #2 with the following results: Fried chicken 110 degrees Fahrenheit. The above meat items were not reheated before served to the residents. 10. On 06/02/24 12:28 PM, DA #2 was wearing gloves on her hands when turned on the stove, contaminating the gloves. Without washing her hands and changing gloves, untied the bread bag and used her contaminated gloved hand to remove slices of bread and placed them on the tray. She unzipped the plastic bag that contained slices of cheese, removed slices of cheese with her contaminated hand and placed them on top of the slices of bread to be used in making grilled cheese sandwiches to be served to the residents who asked for grill cheese sandwich with their meal. The surveyor immediately asked the Dietary Employee what you should do after touching dirty objects and before handling food items? DA #2 stated, I should have change gloves and washed my hands. 11. A facility policy titled, Employee Cleanliness and Handwashing Technique/Dietary department employees are required to wash their hands on the occasions listed below: Before beginning shift after picking up anything from the floor and any other time deemed necessary.

Based on observations, interviews, facility document review, and facility policy review it was determined that the facility failed to ensure that a nurses wound treatment cart remained locked when left in the hallway without licensed staff remaining with the cart. Findings include: A review of a facility policy titled, Storage of Medications, dated April 2007, indicated, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. During an observation on 06/03/2024 at 3:10 PM, the surveyor observed a 4-drawer cart on the 500-hall parked against the wall with the drawers facing the hallway. The bottom drawer was slightly open. No staff around the cart currently. The surveyor stayed near the cart and within short eyesight of the cart in the hallway. During an observation on 06/03/2024 at 03:25 PM, the surveyor observed staff, residents, and visitors pass the unlocked treatment cart in the hallway. During a concurrent observation and interview on 06/03/2024 at 3:29 PM, Surveyor observed a staff member exit a resident ' s room. Surveyor approached as the staff member pushed in a mechanism on the top right of the cart. Staff member identified as Licensed Practical Nurse (LPN) #17. LPN #17 was asked whose cart is this in the hallway? LPN #17 stated, This is the treatment nurse's cart. Surveyor asked, What did you do to the cart when you walked up to it. LPN #17 stated, I locked it, I fixed it because I am about to walk away from it. Other staff members exited the room and this nurse walked away from surveyor and left the hallway. During a concurrent observation and interview on 06/03/2024 at 3:31 PM, Staff member walked up to cart and introduced self as Registered Nurse (RN) #6. When asked by the surveyor, What should be done to the cart prior to leaving it in the hallway? RN #6 stated, It should be locked because there are supplies and medications in the cart. RN #6 also confirmed that with it unlocked anyone could get in the cart and take the medications or supplies. During the interview the following medications/supplies/cleaning agents were identified: a. A tube of silver silfadiazine b. Single use packages of zinc oxide formula c. Tube of medihoney gel d. Over 20 single use packs of triple antibiotic ointment e. A box of 25 single use packs of triple antibiotic ointment f. Approximately 32 individually wrapped povidone-iodine swabsticks g. A bottle of iodine cleaner h. A spray bottle of wound cleanser i. Multiple Petrolatum dressings j. Multiple Antimicrobial Silver Calcium Alginate Dressings k. Multiple Collagen Dressing with Silver l. Multiple Calcium Alginate Dressing with Antimicrobial Silver m. 5 bottles of prescription nystatin powder n. 3 bottles of Lotion o. Multiple packages of antimicrobial foam dressings p. A container of Germicidal Disposable Wipes q. 1 pair of bandage scissors During an interview on 06/05/2024 at 12:07 PM, the Director of Nursing (DON) was asked by the Surveyor how should a treatment cart be left in the hallway when unattended by licensed staff? The DON stated, They should be locked. The surveyor asked why the treatment cart should be locked? The DON replied, So anyone who wanted, or a resident going down the hallway could not get in the treatment cart.

Surveyor: [NAME], [NAME] Based on observations, interviews, record review, facility document review, and facility policy review it was determined the facility failed to secure residents private health information on facility tablet to prevent unauthorized sharing of electronic medical record (EMR), while leaving the EMR open in the hallway without staff around for 1 (Resident #330) of 1 Resident reviewed for protection on electronic medical record. Findings include: A review of a facility policy titled, Confidentiality of Information and Personal Privacy, dated October 2017, indicated, Our facility will protect and safeguard resident confidentiality and personal privacy. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Assess to resident personal and medical records will be limited to authorized staff and business associates. A review of the Order Summary Report, indicated the facility admitted Resident #330 with diagnoses that included unspecified foreign body in bronchus causing asphyxiation, initial encounter, essential (primary) hypertension, other nonspecific abnormal finding of lung field. The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/02/2024, revealed Resident #330 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated the Resident was cognitively intact. During an observation on 06/03/2024 at 3:10 PM, The Surveyor observed a facility tablet screen showing Resident #330's electronic medical record (EMR). This was on top of the facilities treatment cart parked outside the Resident's room on the 500 hall. Visible on the screen for anyone in the hallway was: a. Facility name b. Resident ' s name c. Status d. Location e. Gender f. Date of birth g. Age h. Physician i. Allergies j. Code status k. Special instructions l. Current Vital signs a. Blood Pressure b. Temperature c. Pulse d. Weight e. Respirations f. Blood sugar g. Pain m. Treatment to be performed n. Picture of Resident During an observation on 06/03/2024 at 3:25 PM, the surveyor observed staff, residents, and visitors pass the open EHR ( Electronic Health Record) in the hallway. During a concurrent observation and interview on 06/03/2024 at 3:29 PM, Surveyor observed a staff member exit Resident #330's room. Surveyor observed the staff member tap the tablet screen on top of the treatment cart which made the screen go white. Staff member identified as Licensed Practical Nurse (LPN) #17. LPN #17 was asked by the surveyor what was done to the tablet screen. LPN #17 stated, I hid it. I fixed it because I am about to walk away. Other staff members exited the room and this nurse walked away from surveyor and left the hallway. During a concurrent observation and interview on 06/03/2024 at 3:31 PM, staff member walked up to the cart and tablet in hallway and introduced self as Registered Nurse (RN) #6. When asked by the Surveyor, What should be done to the EMR in the hallway before entering a Resident's room? RN #6 stated, The computer should be turned off to not show the Residents EHR. It is due to [Health Information Portability and Accountability Act] HIPPA. During an interview on 06/05/2024 at 12:04 PM, the Director of Nursing (DON) was asked by the Surveyor, What should the nurses do in the hallway to the electronic medical record (EMR) on computers and tablets prior to leaving them unattended in the hallway? The DON replied, The lock screen should be put on for the resident's privacy. The Surveyor asked, What can be viewed while the lock screen is not in place while a tablet is on in the hallway with no staff present? The DON replied, Not much because the screen goes blank fast. The Surveyor asked how fast the screens go blank. The DON was unable to provide a set amount of time to when it goes blank. The Surveyor explained the tablet screen showing residents EHR was observed for 19 minutes and never went blank.

Based on observations, interviews, facility document review, and facility policy review it was determined the facility failed to ensure that portable oxygen cylinders were stored securely when not in use for the facility. Findings include: A review of a facility policy titled, Fire Safety and Prevention, dated May, indicated, Oxygen Safety: f. Store oxygen cylinders in racks with chains, sturdy portable carts, or approved stands. Never leave oxygen cylinders free-standing. During an observation on 06/04/2024 at 8:32 AM, Surveyor noted three oxygen cylinders in the 600 Hall therapy gym. Two cylinders were in a portable rolling stand. The third one was free-standing with a regulator in place. No staff around currently. During an observation on 06/04/2024 at 8:45 AM, Surveyor noted three oxygen cylinders in the 600-hall therapy gym. Two cylinders were in a portable rolling stand. The third one was free-standing with a regulator in place. Currently there are no staff in the therapy gym. During a concurrent observation and interview on 06/04/2024 at 9:03 AM, Speech Pathologist #15 confirmed there are three portable oxygen cylinders in the 600-hall therapy gym, two cylinders were in the portable rolling stand and the third is free-standing. Speech Pathologist #15 stated the oxygen is in the gym for residents in therapy that require oxygen usage. Speech Pathologist #15 stated that oxygen should be stored in the oxygen room, in bag on the back of the resident's wheelchair, or in a rolling oxygen cylinder carrier. Speech Pathologist #15 added these storage techniques are used to prevent the cylinder from falling over which could cause the cylinder to explode. During a concurrent observation and interview on 06/04/2024 at 09:09 AM, Licensed Practical Nurse (LPN) #16 confirmed there is three portable oxygen cylinders in the 600-hall therapy gym, two cylinders were in the portable rolling stand and the third one is free-standing. LPN #16 stated the free-standing cylinder is not secured or safe. When asked by the surveyor how portable oxygen should be stored. LPN #16 stated on the back of a resident's wheelchair in a bag, in a rolling oxygen cylinder carrier, or in oxygen storage room rack. LPN #16 added this is to ensure the tank does not tip over and possibly explode. During an interview on 06/04/2024 at 09:13 AM, the Director of Nursing (DON) was asked by the surveyor how portable oxygen cylinders are stored in the facility. The DON stated, In the back of the resident's wheelchair in bag holder, in oxygen rolling cart stand with wheels, or in a rack in the storage rooms on 200, 500, 600 halls. The DON did clarify all care staff transport oxygen in the facility. The surveyor asked, Why is oxygen not stored free-standing in the facility? The DON stated, To prevent the oxygen cylinders from falling over and to promote resident safety.

Based on observations, interviews, and record review, the facility failed to ensure that bathroom call lights had pull strings in place to accommodate the residents needs to call for help while in the bathroom for 4 of 15 resident bathrooms observed for call lights. Findings include: During the initial tour on 06/02/2024 from 10:46 AM through 11:34 AM, the 400-hall had four out 15 shared bathrooms that were identified as not having a call light string attached to the call light system for residents to call for assistance. 1. A review of the Order Summary Report, indicated the facility admitted Resident #7 with diagnoses that included cognitive communication deficit, repeated falls, muscle wasting, and dementia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/2024, revealed Resident #7 had a Brief Interview of Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required maximal assistance for toilet transfer and required moderate assistance for toilet hygiene. Further review of the MDS indicated the resident was continent of bowel. A review of Resident #7's care plan revealed the resident had an activity of daily living (ADL) self-care performance deficit related to weakness. The facility developed interventions to include the resident required extensive assistance of one staff for toileting, but the resident was noted to toilet self independently at times. The care plan also identified the resident was at risk for fall with an intervention to ensure the call light was in reach. During an observation on 06/02/2024 at 11:04 AM, Resident #7's bathroom had a white emergency call box with a red switch located on the wall next to the toilet. There was no pull cord present in the hole within the red switch that would allow for a resident to call for assistance if the resident were on the bathroom floor. During an observation on 06/02/2024 at 3:07 PM, Resident #7's bathroom had a white emergency call box with a red switch located on the wall next to the toilet. There was no pull cord present in the hole within the red switch that would allow a resident to call for assistance if the resident were on the bathroom floor. During an observation on 06/03/2024 at 3:02 PM, Resident #7's bathroom had a white emergency call box with a red switch located on the wall next to the toilet. There was no pull cord present in the hole within the red switch that would allow a resident to call for assistance if the resident were on the bathroom floor. During an interview on 06/04/2024 at 1:43 PM, Resident #7 stated the only way to call for help in the bathroom was to pull down the switch but can only do that if the resident was sitting on the toilet. Resident #7 expressed that if they needed help and weren't sitting on the toilet, the resident would have to yell and wait for help since there was no string present. During a concurrent observation and interview on 06/04/2024 at 1:58 PM, Certified Nursing Assistant (CNA) #18 stated if residents need assistance while in the bathroom, they pull the bathroom call light cord. CNA #18 stated if there is no cord present in the bathroom, staff should stay with the resident for resident safety and staff should notify maintenance via the maintenance log, which is located at each nurse's station. At this time, CNA #18 confirmed the there was no pull string in place in Resident #7's bathroom and that the switch was activated but not notifying staff. During a concurrent observation and interview on 06/04/2024 at 2:15 PM, Licensed Practical Nurse (LPN) #19 verified at the time of the observation there was no pull string in Resident #7's bathroom. LPN #19 stated that no resident should be left in the bathroom unattended and that with no pull cord present in Resident #7's bathroom, the resident was unable to notify staff when help was needed. LPN #19 stated missing call light pull strings should be reported via the maintenance log, which was located at each nurse's station. A review of the facility Maintenance Request was reviewed from 02/11/2024 through 06/04/2024 and there were no entries related to call light strings for 400 hall. During an interview on 06/04/2024 at 2:19 PM, the Maintenance Director confirmed he was not aware of any missing pull strings in the residents' bathrooms and that maintenance should be notified via maintenance logs located at each nurse's station. The Maintenance Director was holding a call light string and a battery and stated he was on his way to fix a nonworking bathroom call light and string in Resident #7's room. 2. During an observation on 06/02/2024 at 10:49 AM, the bathroom in room [ROOM NUMBER] had a white emergency call box with a red switch located on the wall next to the toilet. There was no pull cord present in the hole within the red switch that would allow a resident to call for assistance if the resident were on the bathroom floor. During an observation on 06/03/2024 at 2:58 PM, the bathroom in room [ROOM NUMBER] had the same observation of the emergency call box without a cord present. 3. During an observation on 06/02/2024 at 11:15 AM, the bathroom in room [ROOM NUMBER] had a white emergency call box with a red switch located on the wall next to the toilet. There was no pull cord present in the hole within the red switch that would allow a resident to call for assistance if the resident were on the bathroom floor. During an observation on 06/03/2024 at 3:09 PM, the bathroom in room [ROOM NUMBER] had the same observation of the emergency call box without a cord present. 4. During an observation on 06/02/2024 at 2:59 PM, the bathroom in room [ROOM NUMBER] had a white emergency call box with a red switch located on the wall next to the toilet. There was no pull cord present in the hole within the red switch that would allow a resident to call for assistance if the resident were on the bathroom floor. During an observation on 06/03/2024 at 3:00 PM, the bathroom in room [ROOM NUMBER] had the same observation of the emergency call box without a cord present. During an interview on 06/04/2024 at 2:24 PM, the Director of Nursing (DON) was asked, How do residents call for assistance while in the bathroom? The DON stated if a resident needed assistance while in the bathroom, staff were notified by the resident activating the call light via the pull string. The DON stated the importance of the call light string being in place in the bathroom was to be able to activate when assistance is needed. On 06/04/2024 at 03:01 PM, the Director of Nursing (DON) stated the facility did not have a policy for call lights.

Based on record review, and interview, the facility failed to ensure the physician and family were notified after a resident had a change in condition, resulting in injury, for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents. The findings are: On 09/20/23 at 9:06 a.m., the Surveyor asked Resident #1, Did you receive a chipped tooth from the lift? Resident #1 replied, Yes. The Surveyor asked, When did this happen? Resident #1 replied, A while ago. The Surveyor asked what happened. Resident #1 replied, The CNAs (Certified Nursing Assistants) were getting me up, and the bar hit my mouth, and chipped my tooth and it hurt. Resident #1 opened her mouth and a quarter of an inch of the left front tooth was broken off. The Surveyor asked what time of day this happened. Resident #1 replied, It was late morning, after breakfast, they were getting me up for lunch. The Surveyor asked if this had been reported. Resident #1 replied, I don't know. The Surveyor asked if she saw the dentist. Resident #1 replied, I did a few days ago. The Surveyor asked if staff rush when providing care. Resident #1 replied, I don't like the lift because I've been banged around so many times, and I'm picky, so it takes a while. Review of the Care Plan with a revision date of 09/03/21 noted Resident #1 required a mechanical lift with the assistance of two staff persons for transfers. A review of the Incidents by Incident Type documentation dated 03/20/23 through 09/20/23, provided by the DON on 09/20/23 at 7:43 a.m., did not include an incident for Resident #1 regarding a chipped tooth. A review of Resident #1's Progress Notes from 01/04/23 at 2:11 PM to 09/19/23 at 11:16 PM did not address an incident of Resident #1 chipping a tooth. A review of the Grievance Logs dated 06/01/23 through 08/31/23, provided by the Administrator on 09/20/23 at 8:12 a.m. did not include a grievance filed for Resident #1 regarding a chipped tooth. On 09/20/23 at 9:20 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #1 how Resident #1 obtained a chipped tooth. LPN #1 replied, I heard about it four weeks ago, one of the CNAs told me, the bar on the lift swung and chipped [Resident #1's] tooth. The Surveyor asked what did you do about it after you found out. LPN #1 replied, I went and told the Social Worker, they usually are the ones who do the grievances, and I told the ADON [Assistant Director of Nursing]. The Surveyor asked if she filled out an Incident and Accident [I & A] form. LPN #1 replied, It didn't happen on my shift. I just heard about it and relayed the message to everyone. On 09/20/23 at 9:50 a.m., the Surveyor asked the Social Worker what the staff are supposed to do if a resident obtains an injury. The Social Worker replied, If a CNA, they notify the nurse, and the nurse will assess/evaluate the resident, notify the doctor, family, and dentist, start an I & A and notify the DON and Administrator. On 09/20/23 at 9:55 a.m., the Surveyor asked the ADON what the staff are supposed to do if a resident obtains an injury. The ADON replied, Report to the floor nurse, the nurse investigates and opens an I & A, message the physician, call the family. We discuss I & A interventions during stand-up meetings and try to prevent it from happening again. On 09/20/23 at 10:02 a.m., the Surveyor asked the DON what the staff are supposed to do if a resident obtains an injury. The DON replied, The CNA reports to the nurse, the nurse completes an I & A, after the I & A, I review the next day, it goes before the IDT [Interdisciplinary Team), and make sure interventions are in place. A policy titled, Accidents and Incidents - Investigating and Reporting, provided by the DON on 09/20/23 at 10:20 a.m. documented, .Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc.[etcetera], occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included . a. The date and time the accident or incident took place; b. The nature of the injury .; c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified .; h. The date/time the injured person's family was notified and by whom; .5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence .

Based on observation, record review and interview, the facility failed to report an incident with injury involving 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled resident. The findings are: During an interview on 9/20/23 at 9:06 AM Resident #1 said her tooth was chipped when a bar from the lift swung and hit her mouth. The resident was not able to recall the date the incident happened and did not know if the incident was reported. Review of the Care Plan with a revision date of 09/03/21 noted Resident #1 required a mechanical lift with the assistance of two staff persons for transfers. A review of the Incidents by Incident Type documentation dated 03/20/23 through 09/20/23, did not include an incident for Resident #1 regarding a chipped tooth. A review of Resident #1's Progress Notes from 01/04/23 at 2:11 PM to 09/19/23 at 11:16 PM did not address an incident of Resident #1 chipping a tooth. A review of the Grievance Logs dated 06/01/23 through 08/31/23, did not include a grievance filed for Resident #1 regarding a chipped tooth. During an interview on 09/20/23 at 9:20 a.m., Licensed Practical Nurse (LPN) #1 said she heard about the incident four weeks ago. LPN #1 said she told the Social Worker and the ADON [Assistant Director of Nursing]. During an interview on 09/20/23 at 9:50 a.m., the Social Worker said she was unaware of Resident #1 broken tooth. The Social Worker said the CNA should notify the nurse if there is an injury, and the nurse should notify the doctor, family, and dentist, start an I&A and notify the DON and Administrator. During an interview on 9/20/2023 at 9:55 a.m., the Assistant Director of Nursing (ADON) said she was not aware of Resident #1 broken tooth and confirmed the nurse should have completed an I&A report which would be discussed during stand-up meetings. During a meeting on 09/20/23 at 10:02 a.m., the DON said she didn't know Resident #1 had a chipped tooth and confirmed there was not a grievance or I&A completed. A policy titled, Accidents and Incidents - Investigating and Reporting, provided by the DON on 09/20/23 at 10:20 a.m. documented, .Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc.[etcetera], occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence .

Based on observation, record review, and interview, the facility failed to ensure that the foods stored in the freezer were covered and sealed to minimize the potential for food-borne illness for the residents who their received meals from 1 of 1 kitchen, dietary staff washed their hands between dirty and clean tasks, and before they handled clean equipment or food items to prevent potential for cross contamination. These failed practices had the potential to affect 127 residents who received meals from the kitchen (total census: 127), as documented on a list provided by Dietary Supervisor on 05/10/23 at 10:55 AM. The findings are: 1. On 05/08/23 between 11:30 AM and 12:54 PM, the following were observed in the kitchen: a. Dietary Employee #4 carried 2 stacks of glasses with the glasses against his shirt. b. Dietary Employee #3 held a cup by the top rim and was used it to scoop ice from the large ice machine. He turned and handed the ice filled cups to Dietary Employee #4 who held them by their rims to position for filling. c. A bag of bread, open to air, was on a shelf above the worktable next to the spices. d. Dietary Employee #5 was serving on the left side of the tray line. As he reached across the line for the items located on the far right, his clothing brushed the food items already on the plate. 2. On 05/09/23 at 12:35 PM, DE #1 pushed a cart towards the steam table. She picked up the tray cards and placed them on the trays. Without washing her hands, she picked up the cups that contained beverages by their rims and placed them on meal trays to be served to the residents for lunch. 3. On 05/09/23 at 12:36 PM, DE #2 picked up condiments, milk cartons, and cartons of supplements and placed them on the meal trays. Without washing his hands, he picked up cups that contained beverages and placed them on the meal trays to be served to the residents for lunch. At 1:49 PM, the Surveyor asked, What you should have done after touching dirty objects and before handling clean equipment? He stated, Washed my hands. 4. On 05/09/23 at 2:05 PM, a container of leftover cartons of ice cream from lunch was placed in the freezer. The Surveyor asked the Dietary Supervisor to describe the appearance of the ice cream. She stated,. They were melted. The Surveyor asked, How many cartons of ice cream were left in the container? The Dietary Supervisor counted them and stated, There were 5 cartons of vanilla ice cream, 10 cartons of chocolate ice cream and 34 cartons of strawberry ice cream. The Surveyor asked, Should melted ice cream be refrozen? She stated, No, they shouldn't have put them back in the freezer. We will throw them away. The Manufacturer's Instructions on the carton of ice cream documented, Keep Frozen. 5. On 05/09/23 at 4:26 PM, the following were observed in the walk-in freezer: a. Two opened and unsealed boxes of pie shells b. An opened and unsealed box of bread sticks c. An opened and unsealed box of biscuits d. An opened and unsealed box of hamburger patties e. An opened and unsealed box of pork fritters f. An opened and unsealed box of sausage g. An opened and unsealed box of carrots 6. The facility policy titled, Employee Cleanliness and Hand Washing Techniques, provided by the Dietary Supervisor on 05/10/23 at 10:55 AM documented, Dietary department employees are required to wash their hands on the occasions before beginning shift and any other time deemed necessary.

Based on observation, record review, and interview, the facility failed to ensure that meals were served in a method that maintained the appearance of cold products and temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 22 residents who received meal trays in their rooms on the 100 Hall, 10 residents who received meal trays in their room on the 200 Hall, 18 residents who received meal trays on the 300 Hall, 21 residents who received meal trays in their room on the 400 hall, 7 residents who received meal trays in their room on the 500 Hall, and 16 residents who received meal trays in their room on the 600 Hall, as documented on a list provided by the Dietary Supervisor on 05/10/23 at 10:55 AM. The findings are: 1. Resident #72 had diagnoses of Fracture of Unspecified Carpal Bone, Left Wrist, Subsequent Encounter for Fracture with Routine Healing. Resident was independent with set up assistance for eating. a. On 05/08/23 at 2:55 PM, the Surveyor asked, How is the food here? Resident #72 stated, My only complaint is that the food is horrible, sometimes it is cold, and I have had to send my tomato soup to be warmed up. The oatmeal is so watery I must drink it. Breakfast is probably the coldest meal of the day. 2. Resident #98 was independent with set up for eating. a. On 05/08/23 at 12:50 PM, the Surveyor asked Resident #98 how the meals were. Resident #98 stated, Food is cold when it gets to us at the end of the line. They changed cooks so the food is better, but cold. 3. The following observations were made on the 100 Hall: a. On 05/09/23 at 1:25 PM, an unheated cart that contained trays for lunch, along with two other lunch trays on top of the food cart was delivered to the 100 Hall by CNA #4. At 1:37 PM immediately after the last resident received their tray in their room, the temperatures of the food items on the test tray were checked and read by CNA #4 with the following results: i. Salisbury steak with gravy was 113 degrees Fahrenheit. ii. Mashed potatoes was 106.2 degrees Fahrenheit. iii. Pureed Salisbury steak with gravy was 113.4 degrees Fahrenheit. iv. Peas were 102 degrees Fahrenheit. v. The Ice cream was melted. b. The Surveyor asked CNA #4 to describe the appearance of the ice cream served to the residents. She stated, It was melted. It was less consistency likely of ice cream. c. On 05/10/23 at 8:26 AM, an unheated cart that contained trays for breakfast was delivered to the 100 Hall by CNA #5. At 8:43 AM immediately after the last resident received their tray in their room, the temperatures of the food items on the test trays were checked and read by the CNA #5 with the following results: i. Milk was 57.9 degrees Fahrenheit. ii. Ground sausage with gravy was 105. 4 degrees Fahrenheit. iii. Scrambled eggs were 103. 6 degrees Fahrenheit. iv. Coffee was 126.9 degrees Fahrenheit. v. Pureed sausage was 101.8 degrees Fahrenheit. vi. Pureed scrambled eggs were 101.3 degrees Fahrenheit. vii. Pureed bread with milk was 98.2 degrees Fahrenheit. 4. On 05/09/23 at 1:00 PM, the cartons of ice cream served to the residents who received their meal trays on the 300 Hall Dining Room were melting. The Surveyor asked Certified Nursing Assistant (CNA) #1 who was assisting the residents in the 300 Hall Dining Room to describe the appearance of the ice cream. She stated, It was a little melted. 5. On 05/09/23 at 1:22 PM, the ice cream that was served to the residents on 400 Hall was melted. The Surveyor asked CNA #3 to describe the appearance of the ice cream served to the residents. She stated, It was melting.

Based on observation, interview, and record review, the facility failed to ensure proper placement of a gastrostomy tube was checked per Physicians' Orders prior to use for 1 (Resident #112) of 3 (#63, #93, and #112) sampled residents. The findings are: 1. Resident #112 was admitted on [DATE] with diagnoses of Dysphagia Following Cerebral Infarction and Moderate Protein-Calorie Malnutrition. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/23 documented a score of 9 (8-12 indicates moderately impaired) on the Brief Interview of Mental Status (BIMS). a. Review of Physician Order dated 02/22/23 documented, .Enteral Feed Order, Verify placement via aspiration and auscultation before med admin [medication administration], feeding/flushes . b. Review of Physician Order dated 05/09/23 documented, .Enteral Feed Order two times a day Bolus [named nutrition formula] 1.5 CAL 120ML [milliliters]. Flush With 60ML Before and After Bolus Feeding. 10 AM and 2PM (240 ml/360 CAL= shift) . c. On 05/09/23 at 10:00 AM, Licensed Practical Nurse (LPN) #1 administered tube feeding. LPN #1 failed to aspirate per Physicians' Orders. 2. On 05/11/23 at 8:25 AM, the Surveyor asked LPN #2 What should you do prior to administering enteral feedings? LPN #2 stated, Auscultate. The Surveyor asked, What could happen if Physicians' Orders to aspirate and auscultate are not followed? LPN #2 stated, It could not be in the right place. 3. On 05/11/23 at 8:31 AM, the Surveyor asked LPN #3 What should you do prior to administering enteral feedings? LPN #3 stated, Auscultation and aspiration. The Surveyor asked, What could if you do not aspirate the stomach contents prior to administering enteral feedings? LPN #3 stated, Could be in the wrong spot. 4. On 05/11/23 at 8:35 AM, the Surveyor asked LPN #4 What should you do prior to administering enteral feedings? LPN #4 stated, Auscultation and flush with water. The Surveyor asked, What could happen if you do not aspirate the stomach contents prior to infusing more nutrition? LPN #4 stated, If the Peg tube is out of place, it could mean, anything could go into the abdominal cavity. 5. On 05/11/23 at 8:40 AM, the Surveyor asked LPN #5, What should you do prior to administering enteral feedings? LPN #5 stated, Auscultate and aspirate. The Surveyor asked, What could happen if the Physicians' Orders to aspirate and auscultate are not followed? LPN #5 stated, It could go in the lungs and aspirate. 6. On 05/11/23 at 8:47 AM, the Surveyor asked LPN #6, What should you do prior to administering enteral feedings? LPN #6 stated, Auscultate. The Surveyor asked, What could happen if the Physicians' Orders to aspirate and auscultate are not followed? LPN #6 stated, You could place meds or liquids into the lungs. 7. On 05/11/23 at 9:02 AM, the Surveyor asked the Director of Nursing (DON), What do you expect the nurses to do prior to administering an enteral feeding? The DON replied, Either aspirate or auscultate. The Surveyor asked, What could happen if the Physicians' Orders to aspirate and auscultate are not followed? The DON stated, They could aspirate. 8. The facility policy titled, Enteral Feedings-Safety Precautions, provided by the DON on 05/11/23 at 10:15 AM documented, .Preventing aspiration, #2 Check gastric Residual volume as ordered .

Based on observation, record review, and interview, the facility failed to review at least annually the Coronavirus Disease (COVID-19) Infection Prevention and Control Measures Policy, and ensure staff properly wore face masks to cover their mouth and nose to prevent the potential spread of COVID-19 during a facility outbreak, or other infectious illnesses to the residents and staff in 1 of 1 facility. The findings are: a. On 12/29/2022 at 7:57 AM, upon entry to the facility the Surveyor observed Certified Nursing Assistant (CNA) #1 at the central nurse's station sitting at a computer with her surgical face mask pulled down off of her nose and mouth talking with staff that were present. There were three other staff members around her, one resident was at the nurse's station and multiple residents were in the day area by the nurse's station. As the Surveyor approached CNA #1, the other staff present left the area. The Surveyor asked CNA #1, How should your face mask be worn? She stated, Over my nose. The Surveyor asked, Should your face mask have been off your nose and mouth? She stated, No, ma'am. The Surveyor asked, What is the facility's policy regarding face masks? She stated, We have to wear it at all times covering our nose and mouth. b. On 12/29/2022 at 9:36 AM, the Surveyor observed Licensed Practical Nurse (LPN) #1 sitting at the nurse's station on the 600 hallway on the computer with his surgical face mask pulled down below his nose. One other staff member was present working in the area and there were residents out in the hallway. The Surveyor asked, How should your face mask be worn? He stated, Up over my nose and mouth and pinched at the nose. The Surveyor asked, Should your face mask have been off your nose? He stated, No. The Surveyor asked, What is the facility's policy regarding face masks? He stated, We're to wear them at all times while in the building. c. On 12/29/2022 at 10:58 AM, the Administrator provided lists of COVID-19 positive residents and staff. The lists documented that there were currently three COVID-19 positive residents and two COVID-19 positive staff. e. The Inservice Education Report dated 12/29/2022 provided by the Administrator on 12/30/2022 at 8:37 AM documented, .Masks are to be worn over the nose - in proper way - at all times . f. On 12/30/2022 at 9:42 AM, the Surveyor observed a notice at the Entrance of the facility at the Receptionist Desk that documented, Face Masks Required . Due to the high COVID-19 county transmission rate or a positive case within the facility, face masks are required at this time. Make sure the mask covers your nose and mouth during the entire visit. g. On 12/30/2022 at 9:46 AM, the Surveyor asked the Administrator, Is the facility currently in a COVID-19 outbreak? She stated, Yes, we are. The Surveyor asked, Do you know the date your outbreak testing started? She stated, I'm not sure, the Infection Preventionist will have that date for you. The Surveyor asked, What is the proper way for staff to wear their face masks? She stated, Well, if they are in their office area, they can have it off, and we consider our nurse's stations their office. The Surveyor asked, Is the nurse's station accessible to residents and visitors? She stated, Well, yes but that can also be considered their office. The Surveyor asked, Is the nurse's station contained by walls and a door that can close to seclude staff when they remove their mask during outbreak? She stated, No. h. On 12/30/2022 at 10:07 AM, the Surveyor asked the Infection Preventionist, Are you currently in outbreak testing for COVID-19? She stated, Yes. The Surveyor asked, When did your outbreak testing start? She stated, November 27, 2022. The Surveyor asked, What is the appropriate way for staff to wear their face mask during a COVID-19 outbreak? She stated, They're supposed to wear their mask if they are performing patient care, in patient care areas within six feet of a resident. The Surveyor asked, What is the appropriate way for staff to wear their face mask during a COVID-19 outbreak? She stated, Covering their nose, their mouth, the bottom part of their face. The Surveyor asked, Should it be off of their nose or mouth when they are in an area accessible by a resident? She stated, If they are within six feet of a resident their mask should be on their face. The Surveyor asked, Should all COVID-19 policies be kept up to date? She stated, Yes. i. The Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures Policy dated April 2020 provided by the Administrator on 12/29/2022 at 10:35 AM documented, . Policy Interpretation and Implementation 1. This policy is based on current recommendations for standard precautions and transmission-based precautions, environmental cleaning and social distancing for COVID-19 . 2. While in the building, personnel are required to strictly adhere to established infection prevention and control policies, including: .b. Respiratory hygiene . 3. To address asymptomatic and pre-symptomatic transmission, universal source control is being implemented when county transmission rate is high or there is a covid-19 outbreak in the facility . (1) Anyone entering the facility is required to have a face covering regardless of symptoms . (3) Staff should wear a facemask at all times when in the facility if county transmission rate is high or facility is in an outbreak status . j. The CMS (Centers for Medicare & Medicaid Services) - 20054 (09/2022) Department of Health and Human Services Centers For Medicare & Medicaid Services Infection Prevention, Control and Immunization documented, .Page 4 . All staff are following appropriate source control (i.e., facemasks or respirators) in accordance with national standards . Page 6 . IPCP [Infection Prevention and Control Program] Standards, Policies, Procedures and Education: .The facility established a facility-wide IPCP including written IPCP standards, policies, and procedures that are current and based on the facility assessment [according to 483.70(e)] and national standards (e.g. [for example], for undiagnosed respiratory illness and COVID-19) . The policies and procedures are reviewed at least annually . l. The Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Policy Updated September 23, 2022, provided by the Administrator on 12/30/2022 at 8:37 AM documented, .HCP [Health Care Personnel] could choose not to wear source control when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms) . m. The American Health Care Association (AHCA) Overview of CDC (Centers for Disease Control and Prevention) and CMS COVID-19 Guidance dated September 23, 2022, provided by the Administrator on 12/30/2022 at 8:37 AM documented, .Source Control/ Masking . Health care personnel could choose not to wear source control when in areas restricted from patient access. (Example- offices, break rooms) . During a facility outbreak, everyone in a healthcare setting should wear face coverings or masks .

Based on observation, record review and interview, the facility failed to ensure food was served at temperatures that were acceptable to the residents, to improve palatability and encourage good nutritional intake during 1 of 2 meals observed. This failed practice had the potential to affect residents who received meals in their rooms, including 24 residents on the 100 hall, 14 residents on the 200 Hall, 19 residents on the 300 hall, 28 residents on the 400 hall, 9 residents on the 500 hall, and 13 residents on the 600 Hall, as documented on a list provided by Dietary Supervisor on 01/10/22 at 2:40 PM. The findings are: 1. On 01/10/22 at 8:16 AM, an unheated cart with 24 breakfast trays was delivered to 600 Hall by Certified Nursing Assistant #1. At 8:36 AM, immediately after the last meal tray was served on the 600 Hall, the temperatures of the food items on a test tray from the cart were checked and read by Certified Nursing Assistant (CNA) #1 with the following results: a. Pureed eggs - 109 degrees Fahrenheit. b. Cream of Wheat - 106 degrees Fahrenheit. c. Sausage links - 101.8 degrees Fahrenheit. d. Pureed sausage - 102.2 degrees Fahrenheit. e. Scrambled eggs - 108 degrees Fahrenheit. f. Oatmeal - 102.4 degrees Fahrenheit. g. Pureed bread with milk - 102 degrees Fahrenheit. 2. On 01/10/22 at 8:42 AM, an unheated cart with 20 breakfast trays was delivered to 400 Hall by CNA #2. There were 2 breakfast trays on top of the cart. At 9:04 AM CNA #2 took one of the breakfast trays from the top of the food cart to deliver to a resident. She was asked to check the temperature of the food items. The temperature of the milk was 48.7 degrees Fahrenheit. CNA #2 left to attend to the resident and License Practical Nurse (LPN) #1 finished checking the temperatures of the food items on the tray. The temperatures of the food items were as follows: a. Milk - 48.7 degrees Fahrenheit. b. Sausage links - 90. 5 degrees Fahrenheit. c. Scrambled eggs - 80 degrees Fahrenheit 3. On 01/10/22 at 9:07 AM, immediately after the last resident received a tray in their room on the 400 Hall, the temperature of the food items on a test tray from the cart were checked and read by LPN #2 with the following results: a. Milk - 50 degrees Fahrenheit. b. Sausage links - 91.4 degrees Fahrenheit. c. Scrambled eggs - 81 degrees Fahrenheit. d. Ground sausage - 101.2 degrees Fahrenheit. e. Oatmeal 113 - degrees Fahrenheit 4. On 01/10/22 at 8:48 AM, a utility cart that contained 6 trays for breakfast was delivered to the 400 Hall by CNA #3. At 9:18 AM, immediately after the last resident received a tray in their room on the 400 Hall, the temperature of the food items on a test tray from the utility cart were checked and read by LPN #1 with the following results: a. Scrambled eggs - 109 degrees Fahrenheit. b. Cream of Wheat - 101 degrees Fahrenheit. c. Oatmeal - 101.3 degrees Fahrenheit. d. Ground sausage links - 93.7 degrees Fahrenheit. e. Pureed eggs - 95.6 degrees Fahrenheit. f. Pureed sausage - 95.9 degrees Fahrenheit. g. Pureed bread with milk - 98.4 degrees Fahrenheit. h. The ice cream was melted. At 9:20 AM, LPN #1 was asked to describe the appearance of the food and stated, .ice cream was melted. 5. On 01/10/22 at 9:21 AM, the Assistant Director of Nursing was asked about the temperature of the food items served to the residents. She stated, It could have been higher. I feel like it's cold. 6. On 1/10/22 at 9:26 AM, CNA #2 was asked about the temperature of the food items served to the residents. She stated, It was a bit cold. I was the only one passing out trays. 7. On 01/10/22 at 9:57 AM, Resident #222's daughter was present in the resident's room. When asked about the food provided, the daughter stated, .we have been working on that . She stated the food was cold.

Based on observation and interview, the facility failed to ensure foods stored in the storage area, refrigerator and freezer were sealed, labeled and dated; the kitchen and dry storage area floors, walls, baseboards, equipment / appliances, ice machine, and air vents were maintained in clean condition; expired food items were promptly removed from stock and discarded; leftovers were promptly utilized or discarded; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 129 residents who received meals from the kitchen (Total Census: 131), as documented on a list provided by the Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 4:03 AM, the following observations were made in the kitchen: a. An open bag of gravy was on a shelf above the food preparation counter. The bag was not sealed. b. A can opener attached at the end of the food preparation counter had shaving metal on the blade. c. A 64 ounce opened bottle of prune juice was on a counter. The manufacturer's specifications on the bottle documented, Refrigerate after opening. 2. On [DATE] at 4:21 AM, the following observations were made in the kitchen: a. There were 4 bags of hamburger buns with an expiration date of [DATE]. b. An uncovered open box of quick creamy wheat was on a shelf in the storage room. c. An uncovered open box of baking soda was on a shelf above the food preparation counter. 3. On [DATE] at 4:32 AM, an open box of sausage links was on a shelf in the walk-in refrigerator. The box was not covered. 4. On [DATE] at 4:33 AM, the following observations were made in the walk-in freezer: a. An open box of rolls was not covered or sealed. b. An open box of pork loin fritters was not covered or sealed. 5. On [DATE] at 4:41 AM, the ice machine in the receiving area had a wet black residue on the interior panel. Dietary Employee #1 was asked to wipe the black residue on the interior panel of the ice machine. She did so, and the black residue easily transferred to the tissue. She was asked, How often do you clean the ice machine? She stated, I am not sure. At 7:44 AM, the Dietary Supervisor was asked, How often do you clean the ice machine? She stated, Once a month and as needed. She was asked, Who uses the ice from the ice machine. She stated, That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms, and we use it in the kitchen to fill beverages served to the residents at meals. Everybody uses it now. 6. On [DATE] at 4:44 AM, the cabinet below the deep fryer had an accumulation of caked-on, black, greasy residue, dirt, and debris at the bottom of it. Dietary Employee #1 was asked to describe what was found inside the cabinet below the deep fryer. She stated, Grease with a build-up of crumbs. She was asked, How often do you clean it? She stated, They usually clean it every Friday. She was asked, Does it look like it has been cleaned every Friday? She stated, No. It doesn't. 7. On [DATE] at 5:05 AM, the following observations were made in the kitchen area: a. A thick black residue was sticking out of the two ceiling vents above the food preparation area b. The floor and the corners throughout the kitchen were stained. Loose food items, butter, and pepper packages were on the floor. c. There were 9 missing tiles below the food preparation sink. The floor by the door leading to the walk-in refrigerator/freezer was chipped. d. The baseboard by the hand washing sink was loose. e. The motor behind the conventional oven had buildup of greasy residue on it. 8. On [DATE] at 5:11 AM, Dietary Employee #2 was wearing gloves when she pushed a cart towards the counter, contaminating the gloves. Without changing gloves and washing her hands, she removed paper cups by the rims from the bag and placed them on the trays. She then poured beverages in the cups to be served to the residents for breakfast meal. 9. On [DATE] at 5:32 AM, Dietary Employee #4 turned on the sink faucet and rinsed tomatoes. She then turned off the sink faucet and placed the tomatoes on the cutting board, contaminating her gloves. Without changing gloves and washing her hands, she removed shredded lettuce from the bag and placed it in individual bowls. She cut tomatoes using the cutting board. She then placed the tomatoes on top of the lettuce to serve to the residents who requested salad with their lunch meal. Dietary Employee #4 was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, Change gloves and wash my hands. 10. On [DATE] at 5:33 AM, Dietary Employee #3 was wearing gloves when she picked up boxes of thickened cranberry juice, apple juice, dairy, water, sweetened tea and orange juice and placed them on the counter, contaminating her gloved hands. Without changing gloves and washing her hands, she picked up cups by the rims and placed them on the trays and poured beverages to be served to the residents on thickened liquids for the breakfast meal. At 6:20 AM, Dietary Employee #3 was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, Change gloves and wash my hands before picking up the cups. 11. On [DATE] at 7:54 AM, the following observations were made in the refrigerator in the unit on 300 Hall: a. Water with a brown substance was standing in the bottom of the refrigerator. b. A tan substance was on the shelves and walls of the refrigerator. c. A carton of whole milk was on a shelf in the refrigerator with an expiration date of [DATE]. d. A zip lock bag of cheese slices was on a shelf in the refrigerator. The bag had no date on it. e. A white Styrofoam container was on a shelf in the refrigerator with and contained an unidentified item. The container was not labeled or dated. f. Five cartons of health shakes were in a bin in the refrigerator with no date on them. g. Two containers of melted raspberry ice cream and a container of melted vanilla ice cream were in the door of the refrigerator. 12. A facility policy titled, Employee Cleanliness and Handwashing Technique, provided by the Dietary Supervisor on [DATE] at 2:09 PM, documented, Dietary department employees are required to wash their hands on the occasions listed below: .f. after disposing or handling of trash or food. g. after handling dirty dishes h. after handling raw poultry, meat or eggs, i. after picking up anything on the floor j. any other time deemed necessary .

Complaint # (AR 715) was substantiated, all or in part, with these findings. Complaint # (AR 764) was substantiated, all or in part, with these findings. A. Based on record review and interview, the facility failed to ensure staff thoroughly investigated a door alarm that went off and resulted in an elopement for 1 (Resident #257) of 2 (Residents #257 and #3) sampled residents who were at risk for elopement. This failed practice resulted in Past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #257, who had been assessed for being at risk for elopement, and left the facility unnoticed by staff when the alarm system sounded, and was found 352 yards from the facility, and had the potential to cause more than minimal harm to 6 residents who were at risk for elopement, according to the list provided by the Administrator on 11/03/2020. The facility removed the Immediate Jeopardy and corrected the practice on 11/02/2020 prior to the survey. The Administrator was notified of the Past Immediate Jeopardy on 11/04/2020. The findings are: 1. Resident (R) #257 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/2020 documented the resident scored 03 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS) and had wandering behavior that occurred 1-3 days. a. The initial elopement assessment dated [DATE] documented the resident has no history of wandering but flagged as a wandering risk with a score of 9. On 10/29/2020 a change was made to the assessment and the scoring was 13. Residents daughter . Daughter states resident had wandering behaviors and episodes of packing his belongings at home. She agrees to wander guard placement and resident name tag. Elopement screenings document there is no 72-hour elopement screening completed on the assessment On 11/01/2020 a significant change in condition wandering assessment was completed scoring a 09 . b. The Physician orders [REDACTED].#FO752B exp (expires) 10/2023 . c. The Care Plan with a revision dated of 11/02/2020 documented, The resident is an elopement risk, wanderer r/t (related to) Dementia, new to facility, high mobility . 11/1/20- ELOPEMENT .11/1/20- REMOVE CODE FROM EXIT DOORS . Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . Resident to wear resident name tag . d. Nurse progress note dated 11/2/2020 04:40 and signed by Licensed Practical Nurse (LPN) #17, documented, Nsg-I&A (Nursing Incident and Accident) Note Physician Contact (Who/When): (Physician) (at) 0210 Family Contact (Who/When): (Daughter) (at) 0430 Incident Description: Some stranger knock at the front door accompanied by the Resident stated that he found Resident at the gas station by the corner without incident as Resident wearing a nametag with the facility on it apparently resident got out the building walking towards the gas station, wanderguard bracelet to right wrist in placed. Resident is calm, no agitation noted. Immediate Intervention: Checked resident (at) all times in view, check wanderguard bracelet and nametag in place Vitals: T (temperature) 98, P (pulse) 82, R (respirations) 20, B/P (blood pressure) 136/74, SPO2 (oxygen saturation) 97% R/A 11/2/2020 13:35 Nsg-I&A Follow Up Late Entry signed by DON, documented: Date and I&A Description: 11/2 Resident just roam around the hallway, no agitation noticed, until some stranger knocking at the front door accompanied by the Resident stated he found Resident in gas station by the corner and noticed wearing nametag with facility name on it and that's why he brought him back without incident, wanderguard bracelet to (right) wrist intact. Long Term Intervention: REMOVAL OF DOOR CODES FROM DOORS, BUT WILL BE POSTED AT EACH NURSES STATION Added to the Care Plan: YES Ensure MD & Family Notification: YES . e. On 11/04/2020 at 11:10 AM, the Administrator was asked, How did (Resident #257) get out of the exterior door with his wander guard on? She stated, He didn't go out the front door it is believed he went out the 500 door. When asked, Was his wander guard working? She stated, Yes, it was working. The door has a 5 second egress to get out in case of a fire. He would've had to press on it and press on it until it opened. When asked, Did the wander guard sound? She stated, Yes, it was beeping. (CNA #11) has a statement. He looked out the main door, checked 200, 100, then went to 400 and 500 and didn't see anyone. f. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A) documented . Date and Time Submitted (if known): 11/02/2020 00:00 . Date and Time of Discovery: . 11/01/2020 9:30 PM .Summary of Incident . (Resident #257) eloped from the facility on 11/1/20 at approximately 9:20 p.m. and was returned to the facility by gas station attendant approximately 100 yards from the facility. (Resident #257) was wearing wander guard and it was sounding appropriately. Resident wears badge identifying him as a resident of (Facility) and it was in place at time of elopement . Steps Taken to Prevent Continued Abuse or Neglect during the Investigation . 1. Police, MD, family and Administrator notified 2. Body audit completed with no negative findings. 3. Wander guard checked for placement. 4. All signage of codes removed from all doors. 5. Resident monitoring and redirected as needed. 6. Abuse/ neglect in-service initiated. 7. All other residents with wander guards were checked for placement and alarm working with no negative findings . Witness Statement obtained . g. An OLTC Witness Statement Form dated 11/02/20 at 3:00 pm and signed by Certified Nursing Assistant #11, documented .Witness Full name . (CNA #11) . Job Title (CNA) Shift 3-11 pm I was watching the front desk when a man drove up and (Resident #257) stepped out of the passenger seat. He was unharmed and acting himself. How he got out of the facility was undetermined . h. A facility policy titled Elopement provided by the DON on 11/12/2020 at 12:44 PM documented, . 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing . 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises . 2. The facility removed the Immediate Jeopardy on 11/02/2020 when they implemented the following interventions: a. On 11/1/20 Resident #257 was brought to the facility by a local gas station attendant. He was immediately assessed by charge nurse, (LPN #2) with no injury or distress. This resident is an independent ambulator without any gait deviations or assistive device with his wander guard still in place and working properly. Staff reported wander guard door alarms had sounded and when investigated did not see a resident at entrances until he appeared with gas station attendant at the front door. b. Upon returning to the facility, the resident was monitored throughout the night by staff to ensure safety as an immediate intervention and to redirect behaviors. c. On 11/2/20 at 8:15 am (Administrator) removed all codes from all entry doors in the facility (because of his independent level of function) and posted the codes at each nurses' station and Geri psych was contacted. d. On 11/2/20 an Inservice was completed by Assistant Director of Nursing with all staff stating that the keypad codes to entry doors will be located at each nurse's station. e. On 11/2/20 the Assistant Administrator conducted an in-service to all staff stating, When a door alarm sounds you are to immediately check for the location of the alarm and visually check to see if a resident is near the exit or has exited the building. Do not turn off the alarm without first ensuring that a resident has not exited the building. Report all elopements to the Administrator and DON. B. Based on observation, record review and interview the facility failed to ensure a planned intervention for the use of chair/bed alarms was consistently implemented to alert staff of unassisted transfer attempts and minimize the potential for falls for 1 (Residents #89) and to consistently implement interventions for 2 (Resident #78 and #98) of 2 sampled residents who were high risk for falls. These failed practices had the potential to affect 44 residents with falls and the potential to affect 9 residents with bed/chair alarms in the last 90 days as documented on the lists provided by the Director of Nursing (DON) on 11/12/2020 at 10:22 a.m. The findings are: 1. Resident #89 had [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) with an assessment reference date (ARD) of 10/5/20 documented the resident scored 4 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS), required extensive assistance of 1 person for bed mobility, transfers, and toilet use; was not steady, only able to stabilize with staff assistance, and had 2 falls with injuries and 2 falls with no injuries. a. The care plan dated 3/31/2020 documented, The resident is high risk falls r/t (related to) Dementia with falls documented 5/7/20, 9/10/20, fall with minor injury 8/10/20, 10/11/20, fall with minor injury 10/31/20 . Will be free of falls through next review date . staff education to ensure resident has walker at all times, staff education to encourage resident recline in recline chair, sign on walker to remind resident to use, determine and address causative factor of fall . b. The fall log for August documented 5 falls on 8/4/2020 at 5:45 a.m., 8/9/2020 at 12:05p.m., 8/24/2020 at 7:32 p.m., 8/27/2020 at 7:20 p.m., and 8/30/2020 at 12:26 p.m.; September falls log documented 2 falls on 9/26/2020 at 10:45 p.m., and 9/27/2020 at 7:50 a.m.; October fall log documented 2 falls 10/23/2020 at 2:45 p.m., and at 7:45 p.m. c. On 8/31/2020 at 6:33 a.m., Nsg-I&A Note documented . Incident Description: Nurse was notified by staff that resident attempted to take herself to the restroom. Resident fell in bathroom. Immediate Intervention: ROM (range of motion) intact. Vitals WNL. (within normal limit) Xray of L (left) hip taken. Chair alarm place in recliner. d. On 9/1/2020 at 5:22 p.m., I&A follow up note documented Date and I&A Description: 8/30/20 Nurse was notified by staff that resident attempted to take herself to the restroom. Resident fell in bathroom. Long Term Intervention: staff reeducated on toileting plan and use of pressure alarm on resident AND CONTINUE THERAPY Added to the Care Plan: YES Ensure MD & Family Notification: YES Intervention not changed after injury. e. The Progress notes dated 09/27/2020 at 2:20 a.m., documented, no acute fx (fracture) to rt (right) hip or face bones shown on x-rays . 09/27/2020 7:53 AM Heard resident calling for help and found resident on the floor on buttocks. Bruising to bridge of nose and laceration to right side of forehead. Physician notified, Ok send to ER (emergency room ) if laceration needs sutures) LPN #11 documented, Resident is stable with existing skin conditions from previous fall. No changes. No ER tx (treatment) needed at this time . f. On 10/1/2020 at 11:02 a.m. IDT (interdisciplinary team) weekly fall note documented, Resident had unwitnessed fall on 9/26 at 1733 (5:33 p.m.), minor injury noted, red alert, hit head, abrasions/laceration noted, right hip pain, x-ray negative, long term interventions was therapy to eval (evaluate) wheelchair and drop wheelchair seat and continue on therapy caseload, also had unwitnessed fall on 9/27, no injury noted, long term interventions were room move and staff education on nonskid footwear and use of pressure alarm. no falls since. The nonskid footwear was not documented on the care plan. g. A Progress Note dated 10/19/2020 at 8:13 p.m., documented Resident was found on the floor by CNAs. Abrasion to bridge of nose . and small abrasion on right side of forehead. C/o (Complains of) pain to right hip. Alarm in place and working . h. The progress notes documented, On 10/23/20 at 2:45 a.m., Called to residents' room per (Certified Nursing Assistant) CNA, resident is lying on right side in floor, hollering Somebody help me! Covers are twisted around resident. Long Term Intervention: MD VISIT WITH NEW ORDERS AND BEVELED MATTRESS. Added to the Care Plan: YES Ensure MD & Family Notification: YES. Incident Description: Resident rolled out of bed, was twisted up in covers. Resident laying on right side. Redness to right rib cage, skin intact. No bruising at this time, will monitor for such. Resident denied pain, able to freely move extremities X4, assisted back to bed X2 assist. Immediate Intervention: Incontinent care given, and neuro checks initiated immediately and are remaining WNL. Vitals: B/P 130/69 T 98.3 R 20 Pulse 80, O2 sat 96%. i. A (Nursing)- I&A dated 10/27/2020 at 3:17 p.m., documented, Nsg-I&A (Incident and Accident) Follow Up Date and I&A Description: Upon entering residents room resident was sitting in floor leaning up against BR (bathroom) door facing. Resident was unable to tell me what happened. Resident noted to having a skin tear to palm of right hand. Unable to approximate edges, 75% skin loss to tear. No other redness or bruising noted at this time. BM (bowel movement) noted in toilet, residents brief was not soiled with urine or feces. Upon further investigation, pressure alarm was not sounding, Long Term Intervention: new pressure alarm placed and nonskid to resident's wheelchair Added to the Care Plan: yes, Ensure MD & Family Notification: yes. j. An IDT weekly fall note dated 10/28/2020 documented, Resident had unwitnessed fall on 10/23/20 at 2:45 a.m., no injury noted, long term intervention MD (Medical Doctor) visit with new orders and beveled mattress, resident also had unwitnessed fall on 10/23/20 at 7:45 p.m., minor injury noted, long term intervention nonskid to residents wc (wheel chair) and new pressure alarm placed, no falls since. k. On 11/02/20 at 04:17 PM, resident had non-skid socks on and an alarm to chair. Resident repeatedly states she is worried about her mother who is being cared for by her sister and has to reach them and moved her Broda w/c about the dining room and hall. The staff tell her, her mother's OK and they just talked to her sister and everything is fine. She say's OK thank you and after a few minutes begins all over again. She has a w/c alarm which is working. 2. Resident #98 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD date of 10/10/20 documented the resident scored 4 (0-7 indicates severe impairment) on a BIMS and had two or more falls with injury and no documented falls with major injuries. a. The Care Plan dated 3/31/20 documented the resident is high risk for falls r/t Dementia. Had falls documented 5/7/20, 9/10/20, fall with minor injury 8/10/20, 10/11/20, fall with minor injury 10/31/20. Staff education to ensure resident has walker at all times, staff education to encourage resident recline in recline chair, sign on walker to remind resident to use, determine and address causative factor of fall. b. The fall log for August documented 2 falls: 8/10/2020 at 12:00 p.m., and at 7:40 a.m. The September fall log documented 2 falls: 9/6/2020 at 3:18 p.m. and 9/10/2020 at 5:00 p.m., and the fall log for October 2020 documented 3 falls: 10/1/2020 at 8:45 a.m., 10/11/2020 at 5:05 p.m., and 10/31/2020 at 12:22 p.m. c. On 10/5/2020 an I&A follow up note at 0922 documented, Date and I&A Description: 10/1/20 Staff found resident on floor. When I got to room saw resident on floor feet out in front of him facing the bed with non-skid socks on, was sitting on left hip more than right hip. No injuries noted at this time. Long Term Intervention: toilet after meals and staff education to ensure walker is in reach. Added to the Care Plan: Ensure MD & Family Notification: yes Immediate Intervention: Palpated hip areas denies pain or discomfort assisted to standing position and place back into bed. Xray hip and UA (urinalysis) c/s (culture and sensitivity) . d. The progress notes signed by LPN #8 documented, 10/11/2020 8:17 PM returned from ER new order to hold [MEDICATION NAME] tonight & continue for heart rate < (less than) 60. Sutures to forehead dc (discontinue) in 7-10 days. Incident Description: CNA got this nurse stating resident was on the floor. Resident on floor in front of bed on left side with blood on floor in front of him. He was bleeding from right forehead from laceration and right forearm from skin tears. He was incoherent, responding sometimes to his name. Immediate Intervention: Treated wounds, contacted doctor, transported to emergency care. Transmitted to emergency care the immediate interventions treated wounds, contacted doctor . There was no follow up note no long-term intervention identified to prevent further injury. e. A Nsg I&A notes documented a fall on 10/31/2020 at 12:22 p.m. documented, this nurse found resident sitting with bottom on floor in front of nightstand in bedroom, resident was bare foot, call light had not been pushed. Stated he was not hurting but hit his head. Small laceration above L eyebrow. started neuros, sent to ER (emergency room ) for ct (cat scan) scan. Immediate intervention documented resident stated that he had gotten up to go to the bathroom & lost balance, falling forward into nightstand. Resident denied pain and could move extremities freely. Assisted resident in chair X2 assist. Body audit completed, cleansed laceration above left eye with wound cleanser & also to have a small knot above laceration. started neuros (neurological checks), put on non-skid socks on resident. contacted family & Dr sent to ER for ct. There were no long-term intervention identified to prevent further injury. f. On 11/02/20 at 03:51 PM, the resident had a purple/blue area under his left eye as well as purple area to back of his left hand. The resident had shoes on. 3. Resident #78 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/30/2020 documented the resident scored 13 (13-15 indicates cognitively intact) on a BIMS of and documented wandering behavior not exhibited. a. The Care Plan revised 6/26/2020 documented, Elopement risk with no Wandergard bracelet identified as an intervention. b. The Nsg Elopement Risk with Care Plan 4/25/2020 documented 11-high risk to wander. The Quarterly MDS with an ARD of 9/30/2020 documented wandering as behavior not exhibited, as well as the Quarterly MDS with ARD 6/30/2020 and the Admission MDS 3/30/2020. The admission Nsg Elopement Risk with Care Plan documented 2-low risk. c. On 11/09/20 at 01:24 PM, LPN #16 was asked, Should an intervention be put into place after a fall? Stated, Yes. She was asked, When? Stated, Immediately after the fall, At 1:26 p.m., LPN #8 was asked, Should an intervention be put into place after a fall? Stated Yes Was asked, When? Stated, Immediately after a fall. d. On 11/10/20 at 01:49 PM, the DON was asked, When should a fall intervention be implemented? Stated, immediately. Who should implement the intervention? Stated, The nurse and then we review it the next day. e. The Falls and Fall Risk Managing policy and procedure provided by the DON on 11/11/2020 at 10:29 a.m. documented .if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Staff will re-evaluate the situation and whether it is appropriated to continue or change current interventions. The staff will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls.

Complaint # (AR 154) was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure pain management was provided in accordance with the physician's plan of care, due to failure to ensure the prescribed pain medication was available for administration, resulting in a resident missing 10 scheduled doses of a narcotic [MEDICATION NAME] medication, and failed to ensure the resident's pain level was assessed and documented during the 3-day period when his prescribed pain medication was unavailable for 1 (Resident #1) of 1 (Residents #1) case mix residents who had physician orders [REDACTED]. The failed practices resulted in actual harm to Resident #1, who had multiple pain-producing comorbidities and experienced abdominal pain with nausea and vomiting, requiring transfer to the emergency room for pain management, and had the potential to cause more than minimal harm for 16 residents who had physician orders [REDACTED]. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 2/8/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required extensive assistance of one person for bed mobility and transfer, received scheduled pain medication, experienced pain frequently with a pain intensity of 6 on a scale of 0 to 10 (with 10 being the most severe), had a surgical wound and required surgical wound care, required application of nonsurgical dressings, received intravenous medications, and received an opioid medication on 7 of the last 7 days. a. The Care Plan dated 2/2/18 documented, .The resident has acute pain related to osteo[DIAGNOSES REDACTED], surgical incision to left upper chest . The resident will not have an interruption in normal activities due to pain through the review date . Monitor / record / report to nurse resident complaints of pain or requests for pain treatment . Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain . b. A Physician order [REDACTED].[MEDICATION NAME] HCL ([MEDICATION NAME]) Tablet 10 mg (milligrams) give 1 tablet by mouth every 4 hours for pain . c. The (MONTH) (YEAR) Medication Administration Records (MAR) documented the following scheduled doses of [MEDICATION NAME] were not administered as ordered: .2/6/18 midnight - hold . 4:00 a.m. - hold . 8:00 a.m. - other . 12:00 p.m. - other . Four scheduled doses of [MEDICATION NAME] were missed on 2/6/18. The Nurses Progress Notes dated 2/6/18 documented, .Awaiting Rx (prescription) from MD (Medical Doctor) . d. The (MONTH) (YEAR) Medication Administration Records documented the following scheduled doses of [MEDICATION NAME] were not administered as ordered: .3/3/18 . 8:00 p.m. - hold . 3/4/18 midnight - hold . 4:00 a.m. - hold . 8:00 a.m. - hold . 12:00 p.m. - hold . 4:00 p.m - hold . 8:00 p.m. - hold . 3/5/18 midnight - hold . 4:00 a.m. - hold . 8:00 a.m. - hold . 1.) Nurses Progress Notes dated 3/4/18 documented, .Awaiting delivery from pharmacy . 2.) Nurses Progress Notes dated 3/5/18 documented, .Rx (prescription) sent to MD . 3.) From 3/3/18 at 8:00 p.m. through 3/5/18 at 8:00 a.m., the resident missed 10 doses of scheduled pain medication. 4.) During the 3-day period when the resident's physician-ordered pain medication was unavailable for administration, there was no documentation in the Nurses Notes, Medication Administration Records or elsewhere in the clinical record to indicate the resident's pain was assessed or that any non-pharmacological pain management efforts were made by nursing staff. e. The Hospital Admission Record dated 3/5/18 at 1:04 p.m. documented, .This gentleman is presenting to the emergency department from the nursing home with nausea, vomiting and abdominal pain. He is currently on IV (intravenous) [MEDICATION NAME] for Bacteremia and at L2 - L3 (Lumbar Vertebra #2 to #3) Discitis with Abscess into the left psoas. He was discharged from our facility 2/1/18. Says he is feeling better from the standpoint up until yesterday when he began to have abdominal pain, nausea and vomiting that has persisted . His abdominal pain was completely relieved with 1 dose of [MEDICATION NAME] . f. On 3/20/18 at 2:15 p.m., the Director of Nursing (DON) was asked when she was made aware that Resident #1 had missed 10 doses of [MEDICATION NAME] 10 mg. She stated she did not know Resident #1's medication was unavailable until Monday, 3/5/18. She stated she found out from the Assistant Director of Nursing (ADON), after the ADON had reviewed the narcotic logs that morning. The DON stated the ADON had informed her that the resident had been out of medication from the night of 3/3/18 through the morning of 3/5/18. The DON stated, We immediately called the Doctor to get a hard script (written prescription) . My nurse told me she started faxing him (physician) a refill order the previous Wednesday (2/28/18) or Thursday (3/1/18), before that weekend, but later found out his fax machine was not working. He typically comes to the facility every Thursday morning, but for some reason, he was not given the prescription to sign that Thursday (3/1/18). He was gone sometime around that time on vacation, so I don't know if it was during that timeframe or not. After we discovered that this had happened, we made both the ADONs and the Charge Nurses responsible for going through the narcotic counts and getting the Doctors on Wednesday or Thursday, the prescriptions to sign in-house. When asked for documentation of these corrective actions, the DON stated, We have not documented this anywhere, and I am not aware of involving the Doctors in this process either. The ADONs and Charge Nurses go through the carts, print out the needed hard scripts to get the Doctors to sign when they are here. This is typically done when they are down to 10 pills left, but for residents like (Resident #1), who routinely receive 6 pills per day, that would not be soon enough, so we would probably start the week before they were to run out. The Director of Nursing provided an in-service dated 3/6/18, and signed by the ADONs and Charge Nurses, indicating they were in-serviced on the procedure for the narcotic counts and the timely notification of the physician for prescriptions needed.

Complaint # was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure an infection Control Program was in place to prevent the development and transmission of disease and infection as evidenced by: Failure to ensure isolation precautions were followed consistently during the provision of care to decrease the potential for the spread of Clostridium difficile for 2 (Residents # 1 and 3) of 4 (Residents # 1, 3, 4, and 6) case mix residents who had a [DIAGNOSES REDACTED]. Failure to ensure the disinfectant utilized for daily room cleaning was effective against[DIAGNOSES REDACTED] and failure to disinfect cleaning equipment and supplies after utilizing them in isolation rooms and before taking them into other resident rooms for 2 of 59 resident rooms that housed residents who were positive for[DIAGNOSES REDACTED]; Failure to ensure an incontinent brief was not contaminated prior to use on a resident for 1 (Residents #3) of 2 (Residents 1 and 3) case mix residents who was on isolation and required assistance with incontinent care; Failure to ensure soiled linen from an isolation room was contained and handled to prevent potential cross contamination in the laundry and all housekeeping and laundry staff were knowledgeable of the type of disinfectant to use for laundry contaminated with[DIAGNOSES REDACTED]; and, Failure to ensure documentation regarding infections was complete, to include whether the infections were community acquired or nosocomial, for 2 (Residents #4 and #6) of 4 case mix residents who had Clostridium difficile infections. These failed practices resulted in a pattern of actual harm for Residents # 1 and 3, who acquired Clostridium difficile infections which was identified by Registered Nurse #1 as a nosocomial acquired infection and had not antibotic administration in the past 60 days and had the potential to cause more than minimal harm for 108 residents in the facility who received housekeeping services and used facility linens, according to the Resident Census and Conditions of Residents form received from the Director of Nurses on [DATE] and 81 who were incontinent of bowel or bladder and required assistance with toileting according to a list received from the Director of Nurses on [DATE]. The findings are: 1. The Occupational Safety and Health Administration on-line article titled "CDC (Centers for Disease Control): 'C. difficile' Poses Threats Across All Medical Facilities" and found at http://blogs.hcpro.com/osha/,[DATE]/cdc-c-difficile-poses-threats-across-all-medical-facilities/> documented, "The CDC's Vital Signs <http://www.cdc.gov/vitalsigns/HAI/index.html>, [DATE], reports that while 94% percent of [DIAGNOSES REDACTED]icile infections are related to medical care, only 25% of infections first show symptoms in hospital patients. That means that 75% of [DIAGNOSES REDACTED]icile infections first appear 'in nursing home patients or in people recently cared for in doctor's offices and clinics,' according to the report... 'Illness and death linked to this deadly disease do not have to happen. Patient lives can be saved when health care providers follow the 6 Steps to Prevention, which include key infection control and smart antibiotic prescribing recommendations.' The 6 Steps to Prevention are: ...Test for [DIAGNOSES REDACTED]icile when patients have diarrhea while on antibiotics or within several months of taking them. Isolate patients with [DIAGNOSES REDACTED]icile immediately. Wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there..." 2. The CDC Frequently Asked Questions about Clostridium difficile for Healthcare Providers found at <http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a6> documented, "...How is Clostridium difficile transmitted? Clostridium difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item... How can Clostridium difficile infection be prevented in hospitals and other healthcare settings? ...Use Contact Precautions ... Continue these precautions until diarrhea ceases. Because Clostridium difficile-infected patients continue to shed organism for a number of days following cessation of diarrhea, some institutions routinely continue isolation for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay. Implement an environmental cleaning and disinfection strategy: Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. Consider using an Environmental Protection Agency (EPA) -registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used. (Note: Standard EPA-registered hospital disinfectants are not effective against Clostridium difficile spores.) Hypochlorite-based disinfectants may be most effective in preventing Clostridium difficile transmission in units with high endemic rates of Clostridium difficile infection. ... Recommended infection control practices in long term care and home health settings are similar to those practices taken in traditional health-care settings..." 3. The facility policy titled "Clostridium Difficile" documented, "...Infection Control Protocol and Safety: ... 3. Prevention: ... d. Maintain high degree of sanitation throughout facility... 6. After completion of the procedure, clean, store and/or dispose of equipment and supplies in the appropriate manner as identified per facility infection control policy..." 4. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] documented the resident had moderately impaired cognitive skills for daily decision making per a Staff Assessment of Mental Status, required extensive assistance with toilet use, was always incontinent of urine and bowel and had a feeding tube. a. The "Standard Care Plan for Skin Integrity" dated [DATE] and updated on [DATE] documented, "...Incontinent care after each incontinent episode using soap and water or peri-wash..." b. The Nurses Notes dated [DATE] at 10:10 a.m. documented, "...Presents (with) liquid yellow foul smelling stools. Obtained order check stool for [DIAGNOSES REDACTED]." c. The laboratory report dated [DATE] documented Clostridium difficile [MEDICATION NAME] and toxins were positive for [DIAGNOSES REDACTED]. The [DATE] "Monthly Nosocomial Report for Individual Nursing Units" documented the resident had [DIAGNOSES REDACTED] and was on contact isolation. The form did not document if the [DIAGNOSES REDACTED] was community acquired or nosocomial. d. A physician order [REDACTED]. diff." e. On [DATE] at 2:04 p.m., Certified Nurse Assistants (CNAs) # 1 and 2 provided incontinent care following an episode of urine and bowel incontinence. CNA # 1 provided incontinent care, during incontinent care the resident's brief dropped to the floor. The brief was picked up by CNA # 2 and was put in place on the resident. f. On [DATE] at 10:15 a.m., Housekeeper # 1 was present in the resident's room wearing a gown and gloves. Housekeeper # 1 had a spray bottle of Simple Solutions # 51 in the room on the floor, a mop was leaning against the wall inside the door. Housekeeper # 1 sprayed the sink area with Simple Solutions # 51 and wiped the sink area with a wet cloth. Resident # 3 pointed to something on the floor. Housekeeper # 1 put the spray bottle and cleaning cloth on the floor. Housekeeper # 1 picked up the item and placed it in the bio hazardous trash then picked up the Simple Solutions # 51 spray bottle and cleaning cloth from the floor. Housekeeper # 1 then sprayed and wiped the over bed table (top, support bar and legs), the bed side tables, the top of the TV and window ledge. Housekeeper # 1 placed the cleaning cloth in a plastic bag then put the plastic bag and spray bottle of Simple Solutions # 51 on the floor next to the mop. Housekeeper # 1 was asked, "Is Simple Solutions disinfectant the only thing you use to clean with in the isolation room?" Housekeeper # 1 stated, "Yes, we use it everywhere." Housekeeper # 1 mopped the resident's room while wearing the same gloves, removed the mop head when done and placed it in the plastic bag with cleaning cloth. Housekeeper # 1 removed her gloves, washed her hands, picked up the plastic bag with the cleaning cloth and mop head, the Simple Solutions # 51 spray bottle and mop handle. Housekeeper # 1 put the mop handle and Simple Solutions # 51 spray bottle on the housekeeping cart outside Resident # 3's room. Housekeeper # 1 then took the plastic bag to the housekeeping closet on the 100 hall and placed the mop head and cleaning cloth into a mop bucket that had mop water. Housekeeper # 1 was asked, "What's in the bucket of mop water?" Housekeeper # 1 stated, "Same thing we clean with Disinfectant # 51." The Natural Solutions (Simple Solutions) # 51 One Step Disinfectant Germicidal Detergent bottle label documented, "Disinfectant, Cleaner, Mildew stat, Fungicide and Virucide. Active Ingredients: Didecyl [MEDICATION NAME] Ammonium Chloride ... [MEDICATION NAME] ammonium chloride ... Virucidal Performance: ... found to be effective against the following viruses on hard, non-porous environmental surfaces: Avian influenza ... Human Coronavirus, Hepatitis B virus, Human Immunodeficiency Virus type 1... Hepatitis C Virus, Herpes Simplex Virus type 1, Respiratory syncytial virus, Herpes Simplex Virus Type 2, Cytomegalovirus, Avian Influenza A (HSN1) virus. Fungicidal Performance: ... this product is highly effective against the following: Aspergillums Niger, [MEDICAL CONDITION][MEDICATION NAME], Tricophyton mentagrophytes..." This product did not claim to be effective against Clostridium difficile nor did it contain bleach or another EPA-approved, spore-killing disinfectant. 5. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, was totally dependent for toilet use and was always incontinent of urine and bowel. a. Nurses Notes dated [DATE] at 2:50 p.m. documented, "This a.m. presents (with) liquid foul smelling stools. Obtained order check stool for [DIAGNOSES REDACTED]." b. A laboratory report dated [DATE] documented Clostridium difficile [MEDICATION NAME] and toxins were positive for [DIAGNOSES REDACTED]. c. A physician order [REDACTED]. diff." d. The June and [DATE] "Monthly Nosocomial Report for Individual Nursing Units" documented the resident had [DIAGNOSES REDACTED] and was on contact isolation. The form did not document if the [DIAGNOSES REDACTED] was community acquired or nosocomial. e. A physician order [REDACTED]." 6. On [DATE] at 9:07 a.m., the Director of Nurses and Registered Nurse (RN) # 1, the Infection Control Nurse, were asked to review the infection control logs (Monthly Nosocomial Report for Individual Nursing Units) with this surveyor. RN # 1 was asked to see if there was any additional information regarding if [DIAGNOSES REDACTED] infections were nosocomial for the resident's previously discussed. RN # 1 stated she would research it and let the surveyor know. At 11:15 a.m., RN # 1 stated, "I did not look at (Resident # 1) and (Resident # 3) anymore because I know they are mine. They are nosocomial [DIAGNOSES REDACTED] infections. (Resident # 1) was not on any antibiotics prior to [DIAGNOSES REDACTED] infection and (Resident # 3) wasn't either." 7. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored a 12 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status, required extensive assistance with toilet use, and was always incontinent of urine and bowel. a. The facility's [DATE] "Monthly Nosocomial Report for Individual Nursing Units" documented the resident was admitted from the hospital on [DATE] and was discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. b. The facility History and Physical dated [DATE] documented, "... was admitted to the hospital for UTI (Urinary Tract Infection) and ([MEDICATION NAME]) Resistant [MEDICATION NAME]. She came back on [MEDICATION NAME] but her [MEDICATION NAME] is actually resistant to [MEDICATION NAME] ... Assessment/Plan: 1. UTI: I will discontinue the [MEDICATION NAME] ... 2. [MEDICATION NAME] Resistant [MEDICATION NAME]: I will start her on Linezolid 60 mg (milligrams) (twice a day) for 2 weeks ..." c. The resident was readmitted to the facility from (hospital) on [DATE] with Cellulitis. d. The facility admission orders Cipro 500 mg (milligrams) (per mouth) (twice a day) (times) 10 days ... [MEDICATION NAME] 125 mg (per mouth) (four times a day)." e. A physician order [REDACTED]. f. A physician order [REDACTED]. g. A physician order [REDACTED]." h. A physician order [REDACTED]." i. A laboratory report dated [DATE] documented Clostridium difficile [MEDICATION NAME] and toxins were positive for [DIAGNOSES REDACTED]. j. A physician order [REDACTED]. k. The "Report of Infection or Communicable Disease" form dated [DATE] did not document if the [DIAGNOSES REDACTED] was community acquired or nosocomial. l. The [DATE] "Monthly Nosocomial Report for Individual Nursing Units" documented the resident had [DIAGNOSES REDACTED]. The report did not document if the [DIAGNOSES REDACTED] was community acquired or nosocomial. m. A physician order [REDACTED]." 8. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, was totally dependent for toilet use and was always incontinent of urine and bowel. a. The February 2012 "Monthly Nosocomial Report for Individual Nursing Units" documented the resident had [DIAGNOSES REDACTED]. The report did not document if the [DIAGNOSES REDACTED] was community acquired or nosocomial. b. A laboratory report dated [DATE] documented, Clostridium difficile [MEDICATION NAME] and toxins were positive for [DIAGNOSES REDACTED]. c. A physician order [REDACTED]. [DIAGNOSES REDACTED]." d. The facility's "Report of Infection or Communicable Disease" form dated [DATE] documented contact isolation was discontinued on [DATE]. There was no indication on this form if the [DIAGNOSES REDACTED] was community acquired or nosocomial. 9. On [DATE] at 3:12 p.m., Laundry Employee # 1 removed a plastic apron, helmet with a face shield, and heavy duty rubber gloves from a large plastic bag and put these items on. The employee removed a bag of isolation linens from a red plastic barrel in the dirty laundry area and placed the bag of isolation linen on the floor in front of a washer labeled whites only. Laundry Employee # 1 tore a hole in the outer biohazard bag and placed the bag inside the washer then tore open the inner bio hazardous bag. Laundry Employee # 1 shook and pulled linens out of the inner bag into the washer using her right gloved hand. A wet washcloth fell on to the floor. The employee picked up the wet wash cloth with her right gloved hand and placed it into the washer. Laundry Employee # 1 then placed both of the emptied red bio hazardous bags into an open card board bio hazardous box. There was no lid on the box. Laundry Employee # 1 was still wearing the contaminated gloves when the door was closed and the handled was pulled closed to lock the washer. Laundry Employee # 1 then turned on the washer using her right gloved hand. As Laundry Employee # 1 was asked about the washer setting, water started leaking out of the washing machine door and onto the floor. Laundry Employee # 1 turned the washing machine off, opened the washer door, found a wash cloth caught in the seal, and put the wash cloth into the washer. Laundry Employee # 1 then turned on the washer using her right gloved hand, removed the plastic apron, helmet with face shield and gloves, folded the apron and put all the items back into a large plastic bag without disinfecting any of the items. Laundry Employee # 1 was asked, "Do you do anything special to the washer to clean it after setting it?" Laundry Employee # 1 stated, "No." 10. On [DATE] at 4:02 p.m., the Housekeeping/Environmental Supervisor was asked, "Are you responsible for laundry and housekeeping services?" The Housekeeping/Environmental Supervisor stated, "Yes." The Housekeeping/Environmental Supervisor was asked, "Do you know what (Resident # 3) is in isolation for?" The Housekeeping/Environmental Supervisor stated, "C. diff." This surveyor described observations of linen handling by laundry personnel on [DATE]. The Housekeeping/Environmental Supervisor was asked, "Should laundry workers put bio hazardous bags with linens on the floor in front of the washer?" The Housekeeping/Environmental Supervisor stated, "No." The Housekeeping/Environmental Supervisor was asked, "What should happen with the heavy duty vinyl gloves after they are contaminated by touching isolation linens?" The Housekeeping/Environmental Supervisor stated, "She should have washed them and sanitized them later." The Housekeeping/Environmental Supervisor was asked, "What do you use to sanitize gloves?" The Housekeeping/Environmental Supervisor stated, "Disinfectant # 51." The Housekeeping/Environmental Supervisor was asked, "Did you know disinfectant # 51 is not effective for [DIAGNOSES REDACTED]?" The Housekeeping/Environmental Supervisor stated, "No." The Housekeeping/Environmental Supervisor was asked, "Should the laundry worker cleaned the outside of the washing machine after water ran out of it and after touching the handle and buttons with contaminated gloves?" The Housekeeping/Environmental Supervisor stated, "Yes, if she touched it with her gloves." The Housekeeping/Environmental Supervisor was asked, "What's supposed to happen with bio hazardous bags after the isolation linens are removed from them?" The Housekeeping/Environmental Supervisor stated, "They go into the box maintenance set up." The Housekeeping/Environmental Supervisor was asked, "Why is there no lid on the box?" The Housekeeping/Environmental Supervisor stated, "I don't know. They didn't set it up right. Oh, I know what's happened. It's a different company and it doesn't have a lid." The Housekeeping/Environmental Supervisor was asked, "Is the box with no lid going to prevent cross contamination?" The Housekeeping/Environmental Supervisor stated, "No, we will have to get a barrel with a lid." 11. On [DATE] at 9:07 a.m., RN # 1 was asked, "What cleanser is effective for [DIAGNOSES REDACTED] spores?" RN # 1 stated "Chlorine bleach." This surveyor reviewed the housekeeping and laundry observation with the DON and RN. The DON and RN # 1 were asked, "What have you done to investigate [DIAGNOSES REDACTED] infections that are nosocomial?" RN # 1 stated, "I was training housekeeping for deep cleaning of room after isolation discontinued with bleach. I wasn't looking for environmental spread from day to day cleaning. They are supposed to clean isolation rooms last to help prevent cross contamination. We haven't been watching housekeeping or laundry." RN # 1 was asked, "Do you have housekeeping clean their carts with Clorox?" RN # 1 stated, "No." RN # 1 was asked, "Does the disinfectant bottle remain in the isolation room for housekeeping use?" RN # 1 stated, "No, I hadn't thought of that. It needs to stay there in the lock box with the bleach wipes." 12. On [DATE] at 11:05 a.m., Housekeeper #2, working on the 400 hall, was asked, "Is your housekeeping cart labeled for any specific hall use?" Housekeeper #2 stated, "Yes, 200 and 300 but I already started with it today and I moved to 400 hall where I was told to go." Housekeeper #2 was asked, "Do housekeeping carts stay on assigned halls?" Housekeeper #2 stated, "No." Housekeeper #2 was asked, "How do you know if a resident is in isolation?" Housekeeper #2 stated, "The sign on the door." Housekeeper #2 was asked, "Do you know what kind of isolation the resident is in or what's it's for?" Housekeeper #2 stated, "Not really." Housekeeper #2 was asked, "For [DIAGNOSES REDACTED] what is used to clean with?" Housekeeper #2 stated, "Daily, use disinfectant # 51. For deep cleaning use disinfectant and Clorox bleach." Housekeeper #2 was asked, "Did you clean the isolation room for (Resident # 3) lately?" Housekeeper # 2 stated, "Yes, this a.m." Housekeeper # 2 was asked, "Where did you get the disinfectant # 51 bottle?" Housekeeper # 2 stated, "On my cart." Housekeeper # 2 was asked, "When you were done cleaning the room, did you disinfect the bottle of disinfectant # 51?" Housekeeper # 2 stated, "No." Housekeeper # 2 was asked, "Did you mop the room?" Housekeeper # 2 stated, "Yes." Housekeeper # 2 was asked, "What did you do with the disinfectant bottle and mop handle?" Housekeeper #2 stated, "Put them back on my cart."

Complaint # was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to ensure repositioning was provided at least every 2 hours to prevent potential skin breakdown, failed to ensure heel protectors were applied as per the care plan and that heels were offloaded to prevent pressure ulcers to the heels and failed to ensure a skin audit was conducted after a resident was left in the same position in a geri-chair for over 3 hours to identify any new areas of skin breakdown for 1 (Resident #11) of 9 (Resident's #1, #2, #4-#6, #8, #10, #11 and #13) case mix residents who had or were at risk for pressure ulcers. These failed practices likely resulted in actual harm to Resident #11, who developed deep tissue injury to the heels. The facility also failed to ensure soap was rinsed from residents'skin to prevent skin irritation/breakdown for 2 (Residents #3 and #5) of 9 (Resident's #1, #2, #4-#6, #8, #10, #11 and #13) case mix residents who had or were at risk for pressure sores and failed to ensure direct care staff immediately reported changes in skin condition to licensed nursing staff to facilitate prompt initiation of treatment measures for 1 (Resident #3) of 2 (Residents #3 and #11) case mix residents who had changes in skin condition. These failed practices had the potential to affect 52 residents who were at risk for pressure ulcers and 2 residents who had pressure sores, as documented on the Resident Census and Conditions of Residents dated 3/22/11. The findings are: 1. Resident #11 had [DIAGNOSES REDACTED]. The Entry Minimum Data Set (MDS) Assessment with an assessment reference date (ARD) of 3/17/11 documented the resident was admitted to the facility from an acute care hospital on [DATE]. a. The Admission Nursing Assessment Status Upon Admission form dated 3/17/11 documented, "...Skin Condition Using the diagrams provided, indicate all body marks such as ...discolorations, pressure ulcers, or questionable markings. Indicate size, depth (in cms (centimeters)), color..." The body diagram had no documentation or markings on the feet. b. A Braden Scale for Predicting Pressure Sore Risk dated 3/17/11 documented a Total Score of 11 (Total score of 12 or less represents HIGH RISK). c. The Care Plan for Skin Integrity Management dated 3/18/11 documented check marks for "Skin Risk Assessment Score 12 ...Goal: Will have no skin breakdown in next 30 days. ...Routine Skin Care Risk assessment on admission...CNA (Certified Nursing Assistant) inspects resident skin with care daily...Assistance with body alignment ...At Risk Skin Care ...Weekly head-to-toe skin assessment licensed nurse Turn & reposition every 2 hours ...Heel protectors..." d. The Admission Nursing Assessment Skin Audit Records dated 3/17/11, 3/18/11, 3/19/11 and 3/20/11 did not document that there were pressure areas or discolored skin on the resident's feet. e. On 3/22/11 at 12:20 p.m., the resident was positioned in a geri-chair and his feet were in direct contact with the footrest. The resident's feet were not off-loaded. f. The Daily Skilled Nurse's Notes dated 3/23/11 documented, "Turning & Positioning Program". g. On 3/23/11 at 8:20 a.m. and 9:20 a.m., the resident was lying on his back in bed and his feet were positioned directly against the footboard of the bed, with no heel protectors in place. h. On 3/23/11 at 9:30 a.m., CNA #6 and CNA #7 transferred the resident from the bed into a geri-chair. The CNAs used pillows to position the resident's arms and head but did not use pillows under his feet/legs to off-load pressure from his heels. i. On 3/23/11 at 10:30 a.m., the resident was seated in the same position in the geri-chair and his position was marked with tape attaching at each shoulder of the resident's shirt to the geri-chair and labeled with the time. j. On 3/23/11 at 10:55 a.m., the resident was seated in the geri-chair and the tape was intact in the same places at each shoulder. k. On 3/23/11 at 11:40 a.m., 12:10 p.m., 12:25 p.m. and 12:45 p.m., the resident was seated in the geri-chair with the tape intact in the same places at each shoulder. The resident's heels were positioned against the footrest of the geri-chair and were not off-loaded. l. On 3/23/11 at 12:55 p.m., the Director of Nursing (DON) accompanied the surveyor to the resident's room. The resident was seated in the geri-chair with the tape placed by the surveyor intact in the same places at each shoulder. The DON was asked what position the resident was in and stated, "He seems to be in a semi-Fowler's." The DON was asked if she saw the intact tape, labeled with the time it was placed, was seen with the time marked, intact on the shoulders of the resident's shirt to the geri-chair and the DON stated, "Yes." The surveyor informed the DON the resident was seated in the same position in the geri-chair since 9:30 a.m., 3 hours and 25 minutes, was not repositioned or moved to relieve pressure and his feet were not off-loaded. m. On 3/23/11 at 2:35 p.m., the surveyor asked the DON how often residents who are dependent on staff for positioning were to be repositioned and the DON stated, "Every 2 hours." The surveyor asked the DON if dependent residents seated in geri-chairs were to have their positions changed and how often. The DON stated, "Yes. Everyone should be repositioned every 2 hours regardless, without exception." n. On 3/24/11 at 8:50 a.m., the resident was positioned on his back in bed with donut shaped foam devices on each lower leg just below the knees. The resident's heels rested directly against the mattress. The surveyor conducted a complete body audit of the skin as CNAs #6 and #7 bathed the resident. At 9:20 a.m., the CNAs removed the resident's socks. On the sole of the resident's left foot, was a dark purplish discolored area on the heel approximately 3 centimeters (cm) X (by) 1.5 cm and a dark purplish discolored area on the mid-arch approximately 4 cm X 3 cm. The skin was not broken or blistered. On the heel of the right foot, was a dark purplish discolored area approximately 2cm X 1.5 to 2 cm with dry crusted skin and without any break in the skin. The left foot had [MEDICAL CONDITION]. CNA #6 and CNA #7 lifted the resident's feet for the surveyor to view. After the skin audit, the CNAs replaced the resident's socks and then placed the resident's feet directly onto the bed. The CNAs did not comment about the discolored areas on the resident's feet and placed the donut shaped devices around each lower leg below the resident's knees. The CNAs did not off-load the resident's feet. The resident's heels rested directly against the mattress. o. On 3/24/11 at 10:20 a.m., the surveyor asked the DON where skin condition and pressure sores were documented and the DON stated, "It should be documented on his admission. (We do a) full body audit on admission." The DON reviewed the skin assessment diagram sheet and the surveyor asked what was documented on the feet. The DON stated, "No. Nothing is documented (about the resident's feet)..." The surveyor asked the DON when the last body audit was completed and the DON stated, "3/20/11. Zero changes... (no skin audit had been completed the previous day when it was brought to the facility's attention by the surveyor that the resident had remained in the same position in the geri-chair for over 3 hours with no offloading/pressure relief for the heels)". The surveyor asked the DON if any skin changes on the resident's feet were reported and stated, "No. No one has reported any skin issues with his feet." p. On 3/24/11 at 10:45 p.m., the DON and the surveyor viewed the resident's feet and the DON was asked what she saw. The DON stated, "Two dark bruised areas, 3 actually, one on the outer aspect of the heel and 1 on posterior aspect." The DON was asked if the sites were stageable and the DON stated, "No." The surveyor asked the DON who recommended the donut type devices for the resident's legs and the DON stated, "The Treatment Nurse." q. The Nurse's Notes dated 3/24/11 at 11:00 a.m. documented, "This writer was called to (resident) room. Upon arrival found (resident) to have (1) Deep tissue ulcer Stage IV to (resident) (left) foot center, (2) deep tissue ulcer Stage IV to (left) heel (3) Deep tissue ulcer to (right) heel Stage IV. MD notified (new order)...(1) Monitor deep tissue ulcer to center of (left) foot Stage IV Q (every) shift for intactness ...(2) Monitor deep tissue ulcer to (left) heel Stage IV Q shift for intactness...(3) Monitor deep tissue ulcer to (right) heel Stage IV Q shift for intactness...(4) Monitor heel floats (blue donuts) Q shift for placement..." r. On 3/24/11 at 11:15 a.m., the surveyor asked the Assistant Director of Nursing (ADON), who placed the foam donut shaped devices on the resident's legs and the ADON stated, "I did." The surveyor asked the ADON when the devices were placed on the resident's legs and the ADON stated, "Yesterday." The surveyor asked the ADON why the devices were placed on the resident's legs and the ADON stated, "To float the feet." The surveyor asked the ADON if the resident's feet were checked at that time and the ADON stated, "No. I didn't." The ADON measured the areas on the resident's left foot and stated, "2.4 cm X 4.2cm arch area and 3.9 cm X 3.2 cm heel." The ADON measured the right foot heel area and stated, "2 cm X 2 cm." The surveyor asked the ADON when she became aware of the pressure sores and she stated, "Just 30 minutes ago." s. The Weekly Pressure Ulcer Record, provided by the ADON on 3/24/11 at 12:40 p.m., documented, "3/24/11 Risk Factors/Cause Other Immobile Date of Onset: 3/24/11 Site/Location: Deep pressure ulcer (Center of L (left) middle foot) Stage IV Date 3/24/11 Stage Deep Tissue Stage Size in CM 2.4 X4.2; Date of Onset: 3/24 Site/Location: (left) heel-deep tissue ulcer Stage IV Date 3/24 Stage Deep Tissue stage Size in CM 3.9 X 3.2 Wound bed Purple; Date of Onset 3/24/11 Site/Location: R (right) heel-deep tissue ulcer Stage IV Date 3/24 Stage Deep tissue stage Size in CM 2.0 X 2.0 ...Wound bed purple..." t. On 3/24/11 at 3:30 p.m., the surveyor asked LPN #3 if she checked the resident's feet when the last skin audit was completed. The LPN stated, "His feet, make sure they're elevated and ... I didn't recall seeing anything with his feet." LPN #3 did not directly answer the question. 2. Resident #3 had [DIAGNOSES REDACTED]. The 14 Day Medicare MDS with an Assessment Reference Date (ARD) of 3/10/11 documented a Brief Interview for Mental Status (BIMS) score of 8 (a score of 8-12 indicates moderately impaired), the resident had no pressure ulcers and was at risk of developing pressure ulcers. a. The Resident Plan of Care dated 3/11/11 documented, "Activities of Daily Living (ADLs)...Bathing: ext (extensive) X (times) 1... Standard Care Plan for Skin Integrity Skin Risk Assessment Score Indicates Elder at risk for skin breakdown ...Goal: Will have no skin breakdown in next 90 days. ...Routine Skin Care Risk assessment on admission...Bath 3 X Wk (week)...CNA inspects resident skin with care daily...Risk for unavoidable PU (pressure ulcer)..." b. The Braden Scale for Predicting Pressure Sore Risk dated 3/17/11 documented, "...Total Score 17 ...(Mild Risk: Total score 15-18)..." c. On 3/23/11 at 9:45 a.m., CNA #6 and CNA #7 prepared to bathe the resident and CNA #6 stated, "I already put the soap in." CNA #6 added water to the basin which caused soap suds to form. The CNAs did not prepare a basin of rinse water. The CNAs bathed the resident's entire body with soapy water, dried the skin and did not rinse the soap from the resident's skin. At 10:05 a.m., the skin on each of the resident's groins was deep red with an approximately 3.5 cm area on the left groin and an approximately 3 cm reddened area on the right groin. CNA #7 left the room and returned at 10:10 a.m. with a small packet of [MEDICATION NAME] ointment and applied the [MEDICATION NAME] to each groin. d. On 3/23/11 at 10:28 a.m., the surveyor asked CNA #6 what soap was used for the resident's bath. The CNA showed the surveyor a soap dispenser in the 100 hall shower room and stated, "This is care shampoo and body wash." The CNA then opened the soap dispenser and pointed to a full bag labeled, "Dermcen Shampoo and Body Wash." e. On 3/23/11 at 3:00 p.m., the surveyor asked LPN #2 if the CNAs informed her of any problems for the resident and the LPN stated, "No." The surveyor asked the LPN if she was was aware of any reddened areas to the resident's skin and the LPN stated, "No." The surveyor asked the LPN what staff was to do when they found skin changes or redness and the LPN stated, "Report it to me. They verbally report it." The surveyor asked the LPN when the most recent skin audit was conducted for the resident and the LPN stated, "Yesterday." The surveyor asked the LPN if the CNA staff reported the resident had redness in the groin areas after the bath and the LPN stated, "No." The surveyor asked the LPN if the CNA should inform the nurse of skin changes and the LPN stated, "Yes." f. On 3/23/11 at 3:05 p.m., LPN #2 accompanied the surveyor to the resident's room and viewed the perineum and groin areas. The LPN stated, "Yeah, she's excoriated." The surveyor asked the LPN where the reddened skin areas were and the LPN stated, "Groin area." The resident had bilateral bright red areas on the skin of each groin. 3. Resident #5 had [DIAGNOSES REDACTED]. The 5-day Medicare MDS with an ARD of 2/24/11 documented a BIMS score of 7 (a score of 0-7 indicates severely impairment) and that the resident was at risk of developing pressure ulcers. a. The Braden Scale for Predicting Pressure Sore Risk dated 3/7/11 documented, "Total score 14 ... Moderate Risk: Total score 13-14..." b. A Weekly Pressure Ulcer Record, provided by LPN #1 on 3/24/11 at 9:00 a.m., documented, "Date of Onset: 3/23/11 Site/Location: (left) buttock Stage II...Date of Onset 3/23/11 Site/Location: Stage II to coccyx..." c. On 3/23/11 at 11:00 a.m., CNA #6 prepared to bathe the resident. There was peach colored soap in the bottom of a plastic basin and the CNA added water. CNA #6 stated, "Here's the soap, same as last time." The surveyor asked CNA #6 if this was the same body wash used from the shower room and the CNA stated, "Yes." CNA #6 and CNA #8 bathed the resident's entire body with the soapy water and dried the skin and did not rinse the soap from the resident's skin. 4. The manufacturer's recommendations for Derma Cen Apra Care Shampoo/Body Wash, provided by the DON on 3/23/11 at 10:55 a.m., documented, "Directions: ...Rinse completely and repeat if desired. ...Body wash: ...Wash body gently and rinse. ...FOR EXTERNAL USE ONLY Discontinue use should irritation occur." 5. On 3/23/11 at 2:35 p.m., the surveyor asked the DON if the soap was to be rinsed from the resident's skin when they were bathed and the DON stated, "Yes, the soap is to be rinsed."